IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


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Photographic 

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Technical  and  Bibliographic  Notes/Notes  techniques  et  bibiiographiques 


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to 


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D 


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Coloured  covers/ 
Couverture  de  couleur 


I     I    Covers  damaged/ 


Couverture  endommagte 

Covers  restored  and/or  laminated/ 
Couverture  restaurie  et/ou  pellicul6e 

Cover  title  missing/ 

Le  titre  de  couverture  manque 

Coloured  maps/ 

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Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 


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D 


Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material/ 
Reli4  avec  d'autres  documents 

Tight  binding  may  cause  shadows  or  distortion 
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obtenir  la  meilleure  image  possible. 


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fill 


Or 
be 
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fin 
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or 


Th 
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Til 
wl 

Ml 
dif 
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be 

rig 
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This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  film*  au  taux  de  rMuction  indiquA  ci-dessous. 

10X  14X  18X  22X 


12X 


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aox 


U-- 


24X 


28X 


32X 


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The  inrtages  appearing  here  are  the  best  quality 
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The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  —^  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 


Les  images  suivantes  ont  AtA  reproduites  avec  le 
plus  grand  soln,  compte  tenu  de  la  condition  et 
de  la  nettetd  de  rexemplaire  film*,  et  en 
conformit6  avec  les  conditions  du  contrat  de 
filmage. 

Les  exemplaires  orlginaux  dont  la  couverture  en 
papier  est  ImprimAe  sont  filmAs  en  commenpant 
par  le  premier  plat  et  en  terminant  soit  par  la 
dernlAre  page  qui  comporte  une  empreinte 
d'Impression  ou  d'illustration,  soit  par  le  second 
plat,  salon  le  cas.  Tous  les  autres  exemplaires 
orlginaux  sont  filmAs  en  commenpant  par  la 
premiere  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  derniire  page  qui  comporte  une  telle 
empreinte. 

Un  des  syniboles  suivants  apparattra  sur  la 
derniire  image  de  cheque  microfiche,  selon  le 
cas:  le  symbole  — ^>  signifie  "A  SUIVRE".  le 
symbols  V  signifie  "FIN". 


Maps,  plates,  charts,  etc..  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  cartes,  planches,  tableaux,  etc.,  peuvent  dtre 
filmAs  A  des  taux  de  rMuction  diffdrents. 
Lorsque  le  document  est  trop  grand  pour  dtre 
reproduit  en  un  seul  clich6,  il  est  film6  A  partir 
de  Tangle  supArieur  gauche,  de  gauche  d  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  ndcessaire.  Les  diagrammes  suivants 
iilustrent  la  m^thode. 


1 

2 

3 

I 


1 

2 

3 

4 

5 

6 

I   ■      . 


SI 


'S 


I  t 


PULMONARY  TUBERCULOSIS 


ITS  MODERN    PROPHYLAXIS 


AMI  HIE 


THHATMHNT    IN    SPECIAL    INSTITUTIONS    AND    AT    HOML 


AI.VAkliNCA   PKIXH    hSSAY   (^F  THE   COI.I.HGE   OF   PHYSICIANS 

OF    I'HILADLLt'HIA    FOR    THK    YI-;AR    i8f;8 

Kl-VlSbD  AND  ENLARGF.D 


BY  • 

S.  A.   KNOPF,   M.l).  (Pakis  and  Bi: llk \  uic .  N.  V.) 

FIIVMCIAN    TO    1IIK     LlNli     IIPI^AKTME  NT    OF    IIIH     NRW    VOKK    THIIOAT    AMI     NoSK     IIOSI-ITAI.  ;      POKMKK 

ASSISTANT    PIIVMIIAN    to     HKOFHSMiR    HinTWKIirK,    KAIKKSSTKIS    SANATUHllM,    (iKKMANY  ; 

VU  K  IHPMIIKNr     OK     TIIK      TRNNMI  VANIA      SonKlY      HOH      THK      I'K'VKNTION      OH 

Tl  BKHI  IT.OSIS;     FHI.OW    Ol'     IHH     AMKKUAS     A(  ADKMY     AMI    OH     Hi  E 

NHW     Y^'HK     AIAIIKMV    OH     MllllrINK;     I  Al  KEATK    OH    THK 

AIAUHMV     OP     UKKICINK     OH     I'AKI^,      HTt. 


■^TH]   ■■.!  JWIL -^^ 


lUith  E>Ci?cru>tloiis?  .1n^  llliunratione 

nl      1(11' 

MOST    IMI'OKTANT    SANATOIUA    OK    I'.lKi 'IT,  Till ,    I'MIRP    STAli;s,  AN1>   CANADA 

H   .;     E  .•  i  .,6   i  ).v  .;<  ,sr.<.;i' r,  vv.c. 

ni;i  \i»i;i.i'iiiA 
P.   in.A  K  I  s  ro  X's  son  ^v  co. 

loi  2    w  A  I.  NT  1'   s  rKi.i:  r 
1899 


C0I'VKI(,MT.    1899.    BV    S.    A.    K\(M'K.    M.D 


Press  or  Wm,  F.  Fk  l  &  Co, 
I230*34  Sansom  St., 

PHILAUtLPHIA 


To  thf:  t>v>(i(cnf6te,  Statesmen,  an^  pIMlaiUbrorisits  and 
Tin;  /i^aiu}  Hoblc  /iRcn  an^  lUotncn  insidi:  and  ol  tside  of 

TUL  MliDICAI.  PROI"ESSI()N  WflO  LABOR  AND  IIA\F.  LABORED 
ON  BEHALr  Ol-  Tl'BERCULOL'S  INVALIDS.  AND  WHO  HA\E 
HELRFD  TO  DEMONSTRATE  THAT  CoNSl  .WPTION  IS  A  PRE- 
\LNTABI.E  AND  ClRABLi;  IJJSEASE. 


CONTENTS. 

PACK 

Introduction "'■' 

CHAPTER  I. 
Interesting  Data  in  the  History  of  'ruberculosis, 17 

CHAPTER  II. 
Mortality  from  Tuberculosis 27 

CHAPTER  HI. 
Palliological  Proofs  < if  the  Cural)ility  of  Pulmonary  Tuberculosis 3! 

CHAFFER  IV. 
The  Communiral)ility  of  Puhnonnry  Tuberculosis  and  the  Means  to  combat  its  Pro- 

pa};ation  l)y  Individual  Prophylaxis, 35 

(<;)  Infecti(m  by  Inhalation. 
(d)  InftHtion  liy  Ingestion. 
(<r)   Infection  by  Inoculation. 

CHAPTER  V. 
Public  Prophylaxis  in  Regard  to  Tuberculosis  in  Man, S^ 

CHAPTER  VI. 
Sanitary  Laws  and  Regulations  Concerning  the  Prevention  of  Bovine  Tuberculosis,      66 

CHAPTER  VII. 
Preventive  Treatment 79 

CHAPTER  VIII. 
Visits  to  Some  of  the  Most  Important  Sanatoria  and  Special  Hospitals  of  Europe, 

the  United  States,  and  Canada, 9° 

CHAPTER  IX. 
List  of  Sanatoria,  Special  Ho>pitals,  Homes,  Camps,  and  Colonies  for  Tuberculous 

Patients 188 

CHAPTER  X. 
Climatotherapy, 200 

CHAPTER  XI. 
Description  of  an  Ideal  Sanatorium  for  the  Treatment  of  Tuberculous  Patients,     .    204 

ix 


( 


X  CONTENTS. 

CHAl'TKk    XII.  TAGK 

ASrolhorapeutics,  Rest  Cure  and  Exercises 213 

CIIAI'TKR  Mil. 
The  Pneumatic  Cabinet  in  the  Treatment  of  I'lilmonary  Tul)ercuIosis 218 

CHAriKK  XIV. 
ilydrotiierapeiitics  in  the  (leneral  Treatment  of  I'lilmonary  Tulterculosis,     ....     226 

CIIAI'TKR  XV. 
Personal  Hygiene  and  Dress  of  Tuberculous  Patients, 234 

CHAPTER  XVI. 
Dietetic  Trei  .inent, 237 

CIIAI'TKR  XVII. 
Symptomatic  Treatment, 244 

CHAPTKR  XVIII. 
Laryngeal  Tuberculosis  and  Intercurrent  Diseases,  ......        268 

CHAPTER  XIX. 
Educational  Treatment,  Prognosis,  Marriage,  and  Cliildbiith, 277 

CHAPTKR  XX. 
Tuberculin,  t)ther  Culture  Products,  Serums,  etc.,  in  the  Treatment  of  Pulmonary 

Tuberculosis,      286 

CHAPTKR  XXI. 
Consumptives  in  Health  Resorts;  .Sports,  etc. , 290 

CHAPTKR  XXII. 
The  Treatment  of  Consumptives  in  Special  Hospitals 294 

CHAPTKR  XXIII. 

The   Treatment   of   .Anilnilant   Tubereulous    ratlents   in   Private  and   l)i>pensary 

Pr-ictice 297 

CHAITKR  XXIV. 
Treatment  of  Consumptives  nl  their  Home-s, , 302 

t:iIAPTKR  XXV. 
Special  Institutions  for  the  C'onsumptive  Poor;  Care  by  the  Authorities,  and  the 

.Social  Probl-m  of  Tuberculosis, ....     307 

CII.U'TKR  XXVI. 
Clinical  Evidences  of  the  Curability  of   Tuberculosis  hy  the  Hygienic  and  Dietetic 

Treatment.     Conclusions, 328 


LIST   OF  ILLUSTRATIONS. 


PIG. 
I. 

2. 
3. 

5- 
6. 

7- 
8. 

to. 

II. 

12. 
«.?• 

M- 
'5- 
i6. 

17- 
i8. 
iq. 
20. 
21. 
22. 
23- 

24. 
25- 

26. 

27- 

28. 
29. 
30- 
31- 
32. 
33- 
34- 
35- 
36. 
3/- 
38- 
39- 
40. 
41- 


I'Al.K 

Dr.  Hermann  Brehmer, 24 

Dial  Showing  Ki'lalive  Morlality  from  Various  Diseases, ,?o 

4.   Dr.  Knopf's  Elevated  SpillooTi  for  Hospital  and  .Sanatorium  Use.     Figure 

3,  plan  ;   figure  4,  elevation .    .  38 

Elevated  Spittoon  with  Stand,      39 

Dr.  I'redoelil's  Spittoon  for  Factories  and  Workshops, 4I 

Spit  <U|)S  for  Use  on  the  Veranila  and  at  the  Heilside, 4I 

9.   Sealiury  and  Johnson's  Spitting  cup.     (/.    Frame,     h.   Folded  ("ardboanl,     .  4I 

Dr.  Dettlveiler's  "  Hu>tenll.'istlichen," 42 

Dr.  Knopf's  Pocket  Sputum  Flask.     «.  Closed.      /'.  Taken  Apart  for  Cleaning,  43 

Prof.  Fraenkel's  Moutli  Mask, 44 

First  and  Second  Respiratory  Exercises, 83 

Third  Respiratory  Exercise, 84 

Exercise  for  Patients  in  the  I laliit  of  Stooping 84 

Falkenstein  Sanatorium  ((leiieral  View) 92 

X'eranda  at  Falkenstein, 93 

Main  Building  of  the  Sanatorium  at  Ru|>p('rtshain, 95 

.Main  Huilding  of  Dr.  lirehmer's  Sinatoriuin,  Cloerbersdorf 97 

Winter-garilen  of  Dr.  lirehmer's  Sanatorium 99 

Sanatorium  of  Dr.  Roenipirr, lol 

Liegehalle  of  Dr.  Roempler's  .San.itorium, 102 

General   View,  I.iegchalle,  and    Dr.    Weicker's   Canip-lied   at    the    Pueckler 

Sanatorium, '03 

Villas  of  Dr.  Weicker's  Krankenheim 104 

Hohenhonnef  Sanatorium, I06 

Plan  of  Hohenhonnef  Sanatorium 107 

Sanatorium  at  Reiholdsgii'ni '09 

Rest  Cure  in  the  Wood-,  at  Reiboldsgriin HO 

Oderherg  Sanatorium, ''5 

Rest  Cure  (lallery  of  the  Canigou  Sanat.orium, 117 

Maritime  Hospital  at  lierck  sur-Mcr 1 19 

Dr.  Turban's  Sanatorium,  Davosplatz, 122 

A  Kiosk  at  the  I.eysin  Sanatorium 125 

Sanatorium  of  Tonsaasen 126 

Alland  Sanatorium, 1 29 

Royal  Hospital  for  Consumption  and  Diseases  of  the  Chest  at  Ventnor,     ...  131 

Ho.spital  for  Consumptives,  I!rompt-.)n  (London),      133 

.\dirondack  Cottage  Sanitarium,  Saranac  Lake,  X.  V. , 140 

Main  Huilding  of  the  Adirondack  Cottage  Sanitarium 141 

Some  Cottages  of  the  Adirondack  Cottage  Sanitariinn.      (Smniner  View),         .  143 

Some  Cottages  of  the  .Adirondack  Cottage  Sanitarium.      (Winter  View),      .    .  144 

xi 


xii 


LIST   OF    ILLUSTKATIONS. 


no,  PAliK 

42.  (IroiiiKl  rinii  of  McAliiin  C<itia|;e  nt  Snnilariuin,  Snrniinc  Lake,  \.  Y 145 

43.  Saii'lnriiiiii  (iiilniiU 148 

44.  I.oomis  Siiiiitnriiiiu  ul  I.ilierty, 150 

45.  A  Colla^;c,  l.iioinis  Sniiiliiriiim  at  I.ilnTly,      I52 

46.  A  ("•illanc  I >niwiiiK  rnoin  nt  till'  l.(><iini.s  Sunitariiiiii 153 

47.  A  Kedrooin  at  the  Loomis  Sanitarium 154 

48.  Pavilion  Dormitory,  Montetlore  I loMie  Country  Sanitarium, 156 

49.  I'astrur  Sanatorium, 158 

50.  St.  Josf|ili  Hospital  for  <  onMunplivt", 161 

51.  'rtif  Sun  imrlors  of  the  Anna  II.  Wll.stach  Cotl.iyc,  (lieslmit  Hill,  I'hilailel- 

I'liin 163 

52.  \iK\tih  Hos|>ital  for  Consumptivrs, 165 

53.  .Sharon  Sanitarium, 166 

54.  Massachux'tts  Stati'  I  lospilal  for  ConMimptives, 16S 

55.  CIcnrral  View  of  the  I'ri'f  Home  for  Consumptives  in  the  City  of  lloston,    .    .  170 

56.  I'lan  of  the  I'lee  I lomc  for  Consumptives  in  the  City  of  lioston, 172 

57.  .Vshi'ville  Sanal(  ri.nn, 174 

58.  Main  lluildinn  of  (he  Sanatorimn  Hyjjeia  at  Cilronille 175 

59.  CottancH  of  the  Sanatorium  Hygeia  at  Citronelle, 176 

60.  " 'I'lic  Home"  at  Denver,  Colorado, 178 

61.  MusUoka  Cotla^i- Sanatorium 183 

62.  A  Cottage  iif  Muskoka  Cottage  Sanatorium,       184 

63.  I.aurentian  Sanatorium 186 

64.  Perspective  \'ie\v  of  an   Ideal  Sanatorium  for  Consumptives.      I,ar|»c  Pavilion 

System, /v/^ctv;/  204  and  205 

65.  Plan  of  the  Ideal  Sanatorium 206 

66.  Plan  of  the  First  Story  of  One  of  the  Pavilions, 208 

67.  Corner  of  Veranda,  with  .Adjustahle  Chair  for  Kest  Cure 2Io 

68.  Usual  .\ttilude  in  an  Ordinary  t'liair,      2l6 

69.  Prof.  Usedom's  l!realhin(;  chair,      216 

70.  Pnennialic  Cabinet 220 

71.  Tuhe  with  Nose-mask, 222 

72.  Dr.  llaruch's  Douche  .Apparatus 227 

73.  Di.ifjram  of  (Water  )  Cooling  Apparatus 229 

74.  Vestsuspei\<iers, 235 

75.  Rest  Cure  at  Home,       303 

76.  Dr.  Harnes'  Humidilier, 304 


INTRODUCTION. 


"  It  is  ill  the  power  <>r  mnii  tn  caiisp  all  parn^lUc  (llsense*  to  liliapiteni  from  tlie 
worlil." — A.  I'itslriir. 


In  tin's  age  of  rapid  printing  and  in  view  of  the  vast  and  exten- 
sive literature  daily  produced  on  nearly  all  subjects  in  medicine, 
one  should  pause  and  think,  and  offer  good  reasons  for  writing 
another  medical  book.  Tuberculosis  pulmonum  is  no  new  disease, 
and  countless  are  the  books  and  monographs  written  on  its  thera- 
peutics. Thus,  in  offering  to  the  Knglis.i-speaking  medical  world, 
and  especially  to  the  medical  profession  of  the  United  States,  to 
which  I  have  the  honor  to  belong,  a  new  book  on  the  treatment 
and  prevention  of  pulmonary  tuberculosis,  I  must  give  weighty 
reasons  for  doing  so. 

First,  I  maj' say  that  I  had  been  encouraged  to  write  this  work  by 
a  number  of  my  colleagues  of  the  United  States  and  l-'ngiano,  who 
had  honored  me  by  reading  my  French  thesis,  which  procured  me 
the  final  degree  at  the  faculty  of  medicine  of  the  University  of 
Paris,  in  June,  1895.  It  was  entitled  "  Les  Sanatoria:  Traitement 
et  Prophylaxie  de  la  Phtisie  Pulmonaire."  Another  encourage- 
ment to  write  down  in  book  form  the  newer  ideas  and  experiences 
of  what  I  like  to  call  modern  phthisio-therapy  I  found  in  the 
interest  which  was  manifested  in  my  occasional  addresses  before 
American  medical  bodies,  and  the  very  kind  reception  which  was 
accorded  to  the  communications  on  this  subject  by  the  medical 
press  of  this  country. 

But,  aside  from  these  encouragements,  I  felt  that  there  was  a  need 
in  the  United  States  of  spreading  the  ideas  and  principles  of  the 
modern  management  of  pulmonary  tuberculosis — ideas  of  which  I 
witnessed  the  best  fruits  during  my  stay  abroad,  especially  in 
Germany  and  in  England. 

That  the  College  of  Physicians  of  Philadelphia  honored  my 
work  with  the  Alvarenga  prize  for  the  year  1898  is,  perhaps,  the 
best  evidence  that  I  had  not  been  mistaken  in  thinking  that  the 
appearance  of  a  book  on  the  .sanitation,  hygiene,  hospitalization, 

xiii 


XIV 


INTRODUCTION. 


I 


and  treatment  of  tuberculous  patients  of  all  classes  of  society 
mi<;ht  find  a  just  recognition  in  this  country,  and  help  to  show 
that  consumption  is,  indeed,  a  preventable  and  curable  disease. 

I  have  arranged  the  Alvarenga  prize  essay  in  chapters,  more 
suitable  for  publication  in  book  form,  and  reinserted  what  I  had 
necessarily  left  out  in  regard  to  personal  experiments  and  works 
previously  published.'  I  have  also  added  a  short  historical  chap- 
ter containing  some  interesting  data  in  the  history  of  tuberculosis. 
But  the  most  considerable  addition  to  this  essay,  and  one  which, 
I  trust,  will  increase  the  interest  in  the  book,  is  the  description 
and  illustration  of  some  of  the  most  important  sanatoria,  special 
hospitals,  homes,  etc.,  for  the  exclusive  treatment  of  consumptives. 

My  object  in  presenting  this  Ijook  to  the  English-speaking 
medical  world  is  to  give  the  latest  thought  of  the  leading  Euro- 
pean and  American  hygienists,  sanitarians,  and  physicians  on  the 
subject  in  question,  in  addition  to  the  results  of  my  own  studies 
and  researches  in  the  field  of  phthisio-therapeutics.  These  have 
been  gained  by  years  of  active  practice  and  actual  living  among 
tuberculous  patients  in  hospitals,  sanatoria,  and  American  and 
European  health  resorts. 

The  desire  to  study  this  disease  more  thoroughly,  with  its  treat- 
ment and  prevention,  dates  back  to  my  early  medical  career  in  my 
former  home  in  Los  Angeles,  Cai.  There,  where  thousands  of 
consumptives  from  all  over  the  United  States  flock  in,  winter  after 
winter,  many  of  them  hopelessly  advanced  in  their  disease,  others 
with  insufficient  means  to  ei'able  them  to  be  idle  long  enough  to 
get  well,  all  believing  that  the  glorious  climate  of  Southern  Cali- 
fornia alone  would  suffice  to  restore  them  to  health,  I  was  much 
impressed  with  the  urgent  need  of  a  more  timely  and  systematic 
treatment  independent  of  climate.  The  perusal  of  the  best  Amer- 
ican and  foreign  literature  on  the  subject  gave  me  the  first  idea  of 
the  feasibility  of  such  a  method. 

But  I  believe  I  have  especially  enriched  my  experience  in  regard 
to  the  difference  between  sanatorium  and  health-resort  treatment 
by  an  extensive  trip,  in  wliicli  I  visited,  in  both  continents,  some 
thirty  sanatoria,  special  hospitals,  and  numerous  lieatth  resorts  con- 
secrated exclusively  to  the  treatment  of  pulmonary  tuberculosis, 

'  As  is  customary  in  an  essay  desliiied  to  cuiiipelc  lur  a  pii/.c,  any  lufiUiDii  of  |)re- 
vioiis  works  whereby  the  iileiility  of  tlie  author  might  he  revealed  must  be  carefully 
avoided. 


INTRODUCTION. 


XV 


I  am  lastingly  indebted,  however,  to  my  distinguished  teacher, 
Herr  Geheimrath  Dr.  Dettweiler,  of  the  Sanatorium  Falkenstein, 
who  appointed  me  his  assistant  at  the  conclusion  of  my  studies  in 
Paris.  During  my  service  in  his  institution  I  believe  to  have  had 
rare  opportunities  to  study  the  treatment  and  management  of 
tuberculous  patients  in  closed  establishments.  On  my  return  to 
the  United  States  I  began  a  series  of  e.xperiments  with  Marmor- 
eck's  antistreptococcic  serum  in  the  mixed  infection  of  pulmonary 
tuberculosis.  Professor  Hermann  M.  Biggs,  of  New  York,  very 
kindly  placed  at  my  disposal  the  necessary  laboratory  and  clinical 
facilities  to  carry  out  these  experiments,  and  I  desire  to  express  here 
my  gratitude  to  him  for  the  many  courtesies  extended  to  me.  I 
shall  speak  of  these  expeiiments  under  the  heading  of  Symptom- 
atic Treatment.  Since  my  appointment  as  Physician  to  the  Lung 
Department  of  the  New  York  Throat  and  Nose  Ho.spital,  I  have 
endeavored  to  study  how  best  to  manage  and  treat  our  dispensary 
cases.  I  consider  this  subject  most  important,  and  have  devoted  a 
chapter  to  it. 

As  to  the  results  of  the  treatment  of  consumption  in  its  various 
stages  by  what  is  commonly  known  as  culture  products,  tubercu- 
liiies,  etc.,  I  will  state  what  I  have  seen  and  learned  from  the  many 
attempts  in  this  direction,  and  will  give  my  reasons  for  preferring 
the  hygienic  and  dietetic  method  in  either  a  closed  establishment  or 
under  careful  medical  supervision  at  home.  Under  the  chapter  of 
Acrotherapeutirs  I  will  describe  my  modified  method  of  the  use  of 
the  pneumatic  cabinet,  and  under  Dietetic  Treatment  I  will  sum- 
mari/.c  my  reCLnt  experiments  with  tropon. 

During  my  visits  to  the  sanatoria  of  Europe  and  the  United 
States  I  have  been  everywhere  so  cordially  received  that  I  find  it 
a  pleasant  dutv  to  thank  all  these  gentlemen  (directors  and  their 
assistants)  once  more  for  their  helpfuhiess  in  making  my  I'oyni^e 
(i'iliidc  so  profitable.  To  compile  the  statistics  on  the  pathologi- 
cal and  clinical  evidences  of  the  curability  of  tuberculosis  pulmo- 
num  T  addressed  several  hundred  letters  of  inquiry  to  the  leading 
medical  authorities  of  this  country  and  of  luirope.  Many  honored 
me  by  replying  in  full  to  my  questions,  and  to  all  of  these  I  wish  to 
express  my  gratitude. 

In  chapter  ix  I  give  a  list  of  sanatoria,  special  hospitals,  homes, 
camps,  and  colonies  existing  in  various  parts  of  the  world  devoted 
to  the  treatment  and  care  of  consumptive  patients.     I  do  not  claim 


XVI 


INTRODUCTION. 


that  this  list  is  complete.  Throughout  the  civilized  world  there  is 
now  a  movement  in  favor  of  such  institutions.  In  Germany  and 
Austria  these  enterprises,  best  calculated  to  combat  the  spread  of 
consumption  among  the  poorer  classes,  are  especially  active  and 
enjoy  the  support  of  royal  personages  and  of  the  general  govern- 
ment. Hardly  a  month  passes  that  some  German  city  does  not 
form  the  project  of  creating  a  sanatorium  for  its  consumptive  poor. 

For  information  concerning  the  work  done  in  Austria,  England, 
France,  Germany,  Italy,  etc.,  since  my  last  visit  to  those  countries 
and  in  the  countries  I  could  not  visit,  I  am  particularly  indebted 
to  Professor  von  Schrotter,  of  Vienna ;  Dr.  F.  R.  Walters,  of 
London  ;  Dr.  L.  H.  Petit,  of  Paris  ;  Dr.  Georg  Liebe,  of  Loslau, 
Germany ;  Dr.  Massalongo,  of  Verona,  Italy ;  Dr.  Klaus  Han.sen, 
of  Bergen,  Norway;  Dr.  Charles  Saugman,  of  Horsens,  Denmark  ; 
Madame  Paolovvskoja,  M.D.,  of  St,  Petersburg,  Russia;  Dr.  Sand- 
fort  Jackson,  of  Brisbane,  Australia. 

Lastly,  I  desire  to  express  my  thanks  to  the  many  State  and 
city  health  officers  of  the  United  States,  who  so  promptly  an- 
swered my  inquiries  about  the  provision  for  consumptives  in  their 
re.spective  States  and  cities,  and  their  laws  and  regulations  con- 
cerning bovine  tuberculosis. 

Notwithstanding  the  care  I  believe  to  have  cxerci.sed  in  writing 
this  work,  it  will  be  far  from  perfect.  There  will  be  errors  by 
omission,  and  probably  also  some  by  conmiission  ;•  for  these  I 
ask  the  indulgence  of  the  reader.  The  book  does  not  claim  the 
title  of  a  te.\t-book  ;  my  earnest  and  only  desire  in  publishing  it  is 
to  endeavor  to  aid  the  sanitarian  and  hygienist  in  their  labors  to 
combat  the  spread  of  tuberculosis.  I  would  show  to  the  statesman 
where  his  duty  lies  in  regard  to  a  disease,  which  is  as  much  a 
social  as  an  individual  physical  affliction,  and  I  hope  to  indicate  to 
the  philanthro^jist  how  he  may  best  aid  the  tuberculous  poor  and 
render  the  greatest  service  to  the  community  at  large.  Finally,  if 
the  present  work  will  aid  some  of  my  fellow-physicians  in  the  man- 
agement and  treatment  of  that  complex  disease  known  as  pulmo- 
nary tuberculosis,  or  phthisis  pulmonalis,  and  if  through  my  con- 
freres, the  general  and  family  physicians,  the  public  will  learn  at 
last  that  consumption  is,  indeed,  the  most  preventable  and  curable 
of  diseases,  I  shall  feel  that  my  labors  in  the  field  of  modern  phthisio- 
therapy  have  not  been  in  vain. 

i6  West  Ninkty  I'inii  Strkk.t,  Nkw  York, 


PULMONARY  TUBERCULOSIS 


ERRATA. 


f)n  page  64  (tenth  line  from  below),  instead  of  "  vigorous  measures'"  read 
"  rigorous  measures." 

On  page  247,  where  it  reads  "  for  two  suppositories,  to  be  applied  within 
twenty-four  hours,"  read  "  for  four  suppositories,  to  l)e  applied  within  forty  eight 
hours.'' 

On  page  252,  where  it  reads  "  Synip.  linionis, 3J»" 

it  should  read  "  Syrup,  limonis Sj" 

And  instead  of  "  Acjua',       q.  s.  ad  .^Jiv," 

it  should  re.id  "  Aipifc, q.  s.  ad  ,^iv. " 

On  page  262  (fourth  line)  it  should  read  "exacerbations'"  instead  of  "exas- 
perations."' 

On  page  272  (thirteenth  line),  instead  of  "stage  of  ulceration"  it  should 
read  "stage  of  resoiulion." 

On  page  289  (eighth  line),  instead  of  "exasperation"  it  should  read 
"  exacerbation." 


'  "''"'";  '/I'  '•?  "/»,V'/'-'  "f/'"-fi'"'/  i'/iijc  ;()fr«i(  ("  if  the  patient  [consumptive]  is  treated 
from  the  beginning,  he  will  get  well''),  Hippocrates,  vol.  vu,  p.  77.  From  Littre's 
I'rench  translation. 

-  I'rancis  Adam's  translation  of  Hippocrates;  quoted  from  Lawrence  V.  Flick's 
"  The  Contagiousness  of  rhthisis,"  Philadelphia,  18S8. 

'  Aretivus,  chap.  111.  "  I)e  raorborum  diuturnorutn  et  acutorum  causis,  signis  et 
curatione." 

17 


XVI 


INTRODUCTION. 


tliat  this  list  is  complete.  Throughout  the  civilized  world  there  is 
now  a  movement  in  favor  of  such  institutions.  In  Germany  and 
Austria  these  enterp'-ises,  best  calculated  to  combat  the  spread  of 
consumption  among  the  poorer  classes,  are  especially  active  and 
enjoy  the  support  of  royal  personages  and  of  the  general  govern- 
ment. Hardly  a  month  passes  that  some  German  city  does  not 
form  the  project  of  creating  a  sanatorium  for  its  consumptive  poor. 
For  information  concerning  the  work  done  in  Austria,  England, 


n 


nary  tuberculosis,  or  piunisis  pumionaiis,  anu  ii  inrougn  uiy  con- 
freres, the  general  and  family  physicians,  the  public  will  learn  at 
last  that  consumption  is,  indeed,  the  iiiost  preventable  and  curable 
of  diseases,  I  shall  feel  that  my  labors  in  the  field  of  modern  phthisio- 
therapy  have  not  been  in  vain. 

i6  West  Ninetv-kiktii  Street,  New  York, 


PULMONARY  TUBERCULOSIS 


CHAPTER  I. 

INTERESTING   DATA   IN   THE    HISTORY   OF 
TUBERCULOSIS. 


In  this  chapter  it  is  not  intended  to  give  a  complete  history  of 
pulmonary  tuberculosis, — a  disease  known  to  the  medical  writers  of 
all  ages, — but  only  to  put  in  relief  some  of  the  interesting  data  in 
connection  with  the  various  views  that  have  been  expressed  on  the 
contagious  nature  of  this  disease  and  the  methods  of  treatment 
instituted. 

Hippocrates,  the  father  of  medicine,  who  lived  from  460  to  377 
B.  c,  gave  us  the  first  ideas  in  regard  to  judicious  exercise  and  the 
rest  cure  when  he  told  us  (vol.  vii,  1  49)  to  have  the  patient  walk 
if  h',  jls  benefited  thereby ;  if  not,  to  rest  as  much  as  possible. 
The  hereditary  tendency  he  mentions  in  his  aphorisms  (sect,  iv,  S). 
He  also  believed  in  the  curability  of  the  disease,^  but  we  see 
nowhere  any  mention  of  its  contagious  nature. 

Isocrates,  who  lived  about  the  fifth  century  before  Christ,  and 
who  shortly  preceded  or  was  a  contemporary  of  Hippocrates, 
taught  that  consumption  was  contagious,  but  he  apparently  had 
few  disciples.- 

Aretaius,^  supposed  to  have  lived  about  the  year  250  n.  c,  has 


'  OiTof  !/v  ff  i'ip,xi}(:  fteiiuTTFi'O/j  i'>/;)f  ;/'i'frii(  ("  if  the  patient  [consumptive]  is  treated 
from  tiie  beginning,  he  will  get  well"),  Hippocr.ites,  vol.  vil,  p.  77.  From  Litlrc's 
I'rencli  trniislation. 

''  Francis  Adam's  trimslation  of  lli[)pocrates;  quoted  from  Lawrence  F.  Flick's 
"  The  Contagiousness  of  Phthisis,"  I'hiladelpliia,  1S88. 

'  Aretxus,  chap.  in.  "  De  rnorboruni  diuturnorum  et  acutorum  causis,  signis  et 
curatione." 

17 


i8 


PULMONARY   TUBERCULOSIS. 


* 


,! 


given  us  excellent  indications  concerning  the  management  of 
phthisical  patients.  He  prescribed  the  sea-coast  as  a  residence,  and 
recommended  sea  voyages  and  e.xercises  followed  by  rest  and 
friction  of  the  skin.  Milk  diet  he  considered  of  great  importance 
in  the  treatment  of  phthisis. 

Celsus  (30  B.  C.-50  A.  D.),  the  Latin  Hippocrates,  recommended 
a  life  in  the  country  for  the  weaker  tuberculous  patients.  For  the 
more  robust  ones  he  prescribed  sea  voyages. 

Pliny  ^  the  elder  (73-23  b.  c),  though  his  views  in  medicine 
were  rather  empirical,  ascribed  a  most  beneficial  action  to  the  sun 
and  to  the  air  of  pine  forests  in  the  treatment  of  phthisis, 

Galen  2  (131-200  a.  d.)  used  to  send  his  patients  to  higher 
altitudes,  believing  that  the  drier  air  of  the  mountains  would  heal 
the  ulceration  of  the  lungs.  Impure  air  he  considered  an  impor- 
tant etiological  factor.  He  was  probably,  next  to  Isocrates,  the 
first  to  think  of  the  contagious  nature  of  pulmonary  tuberculosis. 
("  Poriculosum  prastera  est  consuescere  cum  his  qui  tabe  ten- 
entur.") 

We  must  now  look  to  the  Arabic  school  of  the  tenth  century 
for  further  light.  Avicenna^  (980-1037  A.  d.),  the  most  celebrated 
Arabic  physician  of  that  time,  believed  in  the  contagious  nature 
of  phthisis.  He  chose  mountain  climates  for  his  consumptive 
patients,  and  he  and  his  pupils  recorded  the  first  authentic  cures  of 
the  disease.** 

From  the  eleventh  to  the  sixteenth  century  little  of  importance 
happei.id  in  the  history  of  medicine.  But  with  the  renaissance 
medical  science  also  arose  from  its  slumbers.  Jacobus  Sylvius  ^ 
(1478-1555),  whose  real  name  was  Dubois,  gave  the  first  exact 
description  of  the  tubercle,  and  seems  to  have  had  an  idea  of  the 
close  union  of  scrofula  and  tuberculosis. 

Falloppio  ( 1 523-1 562)  was  evidently  a  firm  believer  in  climate 
as  a  factor  in  the  treatment  of  phthisis  pulmonalis.     He  was  elec- 


1  Littrt,  "  L'hisioire  de  Pline,"  1848. 

'  Boissfau,  "  liistorique  de  la  cont.igion  de  la  plitisie  pulmonaire."     Dans  le  recueil 
de  iti£moires  de  medecine,  chirurgie  et  pharmacie  militaires.     3  .ser.  xxil,  niai  1869. 

'  .\vicenna   was  born  in   Persia  and  liis  real   name  was  Abou-Iba-Sina-Avicenna. 
"  Arabuni  medicorum  principes  canon  nicdicincu  "  (Hoisseau). 

*  Manasse,  "  Die  Heilung  der  Lungentul)erkulose,"  Berlin. 
5  Predoehl,  "  Die  Gescliichte  der  Tuberkulose,"  1888. 


INTERESTING    DATA    IN    THE    HISTORY   OF   TUBERCULOSIS. 


19 


tive  in  the  choice  of  localities,  and  was  guided  in  this  by  the 
temperament  and  constitution  of  the  patient. 

Montano,  who  lived  at  the  same  period  (1550),  was  a  strong  par- 
tizan  of  the  theory  of  contagion.  According  to  him,  one  could 
contract  pulmonary  tuberculosis  by  simply  walking  witli  naked 
feet  over  the  expectorations  of  a  patient. 

Lazare  Riviere,  of  Montpellier(  1589-165 5),  was  also  a  strong  but 
a  more  scientific  believer  in  the  contagious  nature  of  tuberculosis. 
He  maintained  that  the  transmission  of  the  disease  through  co- 
habitation was  much  more  frequently  the  cause  of  its  development 
than  the  hereditary  influence. 

Van  Helmont  (1577-1644)  believed  in  mountain  and  warmer 
climes  for  the  phthisical  invalid,  and  had  the  courage  to  recom- 
mend wine  as  an  antipyretic. 

Willis,  of  London  (1622-1675),  considered  the  Riviera  as  espe- 
cially conducive  to  the  reestablishment  of  tuberculous  invalids, 
and  was  in  the  habit  of  sending  the  majority  of  his  patients  across 
the  Channel  to  the  southern  portion  of  France  during  the  winter. 

Baglivi  (1669-1707)  deplored  the  inefficiency  of  medicinal 
remedies,  and  has  left  us  a  long  description  of  the  different  regions 
particularly  favorable  for  consumptives. 

The  celebrated  Sydenham,  of  Westminster,  London  (1624-1689), 
must  have  believed  in  vigorous  exercise,  for  he  maintained  with 
certainty  to  have  saved  several  phthisical  patients  through  horse- 
back riding.^ 

Friedrich  Hoffmann  (1660-1742)  believed  in  moderately  warm 
and  moist  atmosphere  as  best  suited  to  consumptives. 

Morgagni  (1682-1771)  was,  perhaps,  next  to  Montano,  the  great- 
est believer  in  the  -.contagiousness  of  tuberculosis  pulmonum.  He 
absolutely  refused  to  perform  an  autopsy  on  individuals  who  had 
died  of  consumption. 2 

Boerhaave  (1668-  1738),  while  not  speaking  in  any  of  his  writings 
of  the  contagious  nature  of  phthisis,  nevertheless  made  it  a  rule  to 
send  his  patients  away  from  the  locality  where  they  had  contracted 
the  disease. 

Van  Swieten   (i 700-1 772),  Boerhaave's  most  celebrated  pupil. 


'  Dupri  de  Lisle,  "  Trail6  de  maladies  de  la  Poitrine  connus  sous  le  noni  de  Phtisie 
Pulmonaire,"  Paris,  1769. 

^  Opera  omnia  physio-medica,  vol.  ill,  de  affeclione  phthisici  sive  tabe. 


20 


PULMONARY   TU13EKCULOSIS. 


'<{ 


followed  the  teachings  of  his  master  in  regard  to  therapeutics,  but 
was  a  convinced  contagionist. 

Dupre  de  Lisle,  in  his  book  which  appeared  in  1769,  speaks 
favorably  of  horseback  riding  as  a  therapeutic  means  in  consump- 
tion, but  insists  that  this  exercise  should  be  regulated  by  the 
physician,  and  he  recommends  country  life  in  addition  for  this  class 
of  patients. 

In  the  library  of  the  Surgeon-General  of  the  United  States 
Army'  is  to  be  found  a  work,  dated  London,  1747,  entitled  "  A 
letter  from  a  physician  in  the  Highlands  to  his  friends  in  London." 
The  author  of  this  work  remains,  however,  unknown.  There  we 
find  for  the  first  time  the  idea  expressed  that  the  hygienic  and 
dietetic  treatment  is  the  most  important  factor,  and  that  climate 
and  medicines  are  only  to  be  considered  as  niore  or  less  precious 
adjuvants.  He  quotes  cases,  of  incontestable  proof,  of  patients 
having  been  cured  in  their  home  climate  by  judicious  diet,  careful 
living,  and  moderate  exercise,  without  the  aid  of  any  medication. 

The  contagious  nature  of  tuberculosis  must  have  been  a  popular 
belief  toward  the  latter  part  of  the  eighteenth  century.  Jeannet 
de  Longrois,  in  his"  Traite  de  la  pulmonic,"  "tells  us  of  an  incident 
at  Nancy,  where  the  municipal  authorities  had  caused  the  furniture 
and  bedding  of  a  woman  who  had  died  of  consumption  (femme 
pulmonique)  to  be  burned.  The  woman  had  contracted  the  dis- 
ease from  another  one  with  whom  she  had  often  shared  the  same 
bed. 

In  Naples,  a  royal  decree,  dated  September  20,  1782,  ordered  the 
isolation  of  consumptives  and  the  disinfection  of  their  apartments, 
personal  effects,  furniture,  books,  etc.,  by  the  aid  of  vinegar,  brandy 
or  lemon-juice,  sea-water,  or  fumigation.  Any  violation  of  this  law 
was  punished,  if  the  individual  was  an  ordinary  mortal,  with  three 
years  in  the  galleys.  If  he  happened  to  be  a  nobleman,  he  was 
sent  for  the  same  time  to  a  fortress,  and  had  to  pay  three  hundred 
ducats.  The  physician  who  failed  to  notify  the  authorities  of  the 
existence  of  a  tuberculous  patient  was  fined  three  hundred  ducats 
for  the  first  offense.  A  repetition  of  the  neglect  would  banish  him 
from  the  country  for  ten  years.  Any  one  aiding  a  consumptive  to 
escape  was  fined  and  imprisoned  for  six  months. 

Portal  (1742-1832)  wrote  that  in  Spain  and  Portugal  the  parents 


■  Index  Catalogue,  vol.  viil,  p.  70. 


»  Paris,  1 781. 


INTERESTING    DATA    IN    THE    HISTORY   OF   TUUERCULOSIS. 


21 


of  a  consumptive  were  obliged  to  notify  the  authorities  when  the 
patient  had  arrived  at  the  last  period  of  the  disease.  This  was 
done  for  the  purpose  of  securing  the  disinfection  of  the  personal 
effects  of  the  patient.  A  similar  regulation  prevailed  at  that  time 
in  Languedoc' 

Toward  the  end  of  the  eighteenth  and  at  the  commencement  of 
the  nineteenth  century  much  discussion  concerning  the  etiology, 
pathology,  and  treatment  of  tuberculosis  was  carried  on  in  the 
various  centres  of  medical  learning,  without  bringing  forth  any  new 
facts  concerning  this  complex  disea.se. 

Brou.ssais  ( 1 772-1 838)  ■  applied  his  general  theory  of  inflamma- 
tion also  to  the  lungs,  and  bled  his  patients,  not  only  in  the  first 
but  even  in  the  more  advanced  stages  of  the  disea.se.  In  his  chap- 
ter "  Traitement  du  deuxieme  degre  de  rinflammation  "  he  says  : 
"  J'ai  saigne  dans  ce  degre  de  phlegmasieet  les  malades  sont  morts, 
j'ai  epargne  leur  .sang  et  je  n'ai  pas  ete  plus  heureux  ;  j'ai  cependant 
obtenu  plus  de  guerisons  avec  la  saignee  que  sans  le  secours  de 
ce  moyen." 

Thomas  Reid,  of  London,  in  his  work  entitled  "  An  Essay  on 
the  Nature  and  Cure  of  Phthisis  Pulmonalis,"  which  appeared  in 
London  in  1785,  draws  again  the  line  of  distinction  between  tuber- 
culosis and  scrofulosis.  He  considers  contagion  a  rare  incident, 
and  only  due  to  cohabitation.  lie  recommends  vegetable  diet  and 
milk  as  essential  in  the  treatment  of  tuberculosis.  At  times  he 
thought  bleeding  beneficial,  but  warns  against  its  excessive  use  by 
saying  that  of  all  diseases  human  flesh  is  heir  to,  in  none  has  bleed- 
ing been  so  frequently  resorted  to  as  in  phthisis,  and  he  thought 
that  the  old  saying  "  the  lancet  has  killed  more  people  than  the 
lance  "  was  particularly  applicable  in  this  case.  Reid  believed  in 
the  curability  of  tuberculosis  of  the  lungs  on  the  same  ground  that 
he  believed  in  the  curability  of  diseases  of  other  viscera. 

A  most  singular  opinion  was  expressed  by  Cullen,  of  Edinburgh 
(1700-1790),  in  regard  to  the  contagious  nature  of  tuberculosis. 
He  claimed  that  a  warm  climate  was  essential  before  contagion 
could  take  place. 

Hufland  ■'   (1781-1827)  believed  in  hereditary  influence  f  .id  a 


'  .Straus,  "  I.a  (uberculose  et  son  bacille,"  Paris,  1S95. 
-  Hroiissais,   "  llistoire  de  i)hlep;masie  chroniques,"  1826. 

'  Hutlaiul,  "  Ueber  die  Xaliir,  Erkeniitniss,  uiid   lieilart  der  Scropliel-Krankheit," 
Berlin,  1S19. 


1 1 


\i 


K 


■if 


22 


PULMONARY   TUBERCULOSIS. 


predisposition  to  the  disease,  but  he  disbelieved  in  the  possibility 
of  contagion /iT .ft'.  Me  and  his  contemporary,  the  distinguished 
Schonlein  (1793- 1864)  were,  however,  strong  advocates  of  climatic 
treatment.'  Schonlein  particularly  thought  to  have  observed 
immunity  from  this  disease  among  the  people  who  had  lived  their 
entire  life  in  mountainous  regions. 

One  of  the  most  interesting  figures  in  medicine  at  the  beginning 
of  this  century,  and  whose  works  are  of  particular  interest  to 
phthisio-therapeutists,  was  doubtlessly  Rene  Theophile  Hyacinthe 
Laennec  (1781-1826).  In  pathology  he  established  the  unity  of 
all  tuberculous  diseases,  and  in  clinical  work  he  taught  us  how  to 
auscultate  the  diseased  chest.  He  believed  in  the  curability  of  the 
disease,  but  it  is  difficult  to  say  whether  or  not  he  believed  tuber- 
culosis to  be  contagious.  The  fact  remains  that  he  died  of  the 
ultimate  results  brought  about  by  an  inoculation  during  an  autopsy 
on  a  tuberculous  subject.  Therapeutically,  he  ascribed  to  ocean 
air  the  best  effects  in  phthisis.  He  was  so  convinced  of  this  that 
during  the  latter  stage  of  his  disease  he  had  the  sea  air  produced 
artificially  in  his  bedroom. 

At  the  end  of  the  last  century  (1791)  May  endeavored  to 
demonstrate  that  the  dietetic  treatment  was  all  that  was  necessary 
for  a  successful  issue  in  the  treatment  of  phthisis  pulmonalis. 
Curchot  and  Carriere  placed  their  faith  in  buttermilk  and  in  the 
grape  cure. 

One  of  the  next  most  important  events  in  the  history  of  tuber- 
culosis was  Villemin's  communication  to  the  Academy  of  Medicine 
of  Paris  on  December  5,  1865,  wherein  he  demonstrated  the  inocula- 
bility  of  tuberculosis  and  the  necessity  of  classifying  this  affection 
under  virulent  diseases.  These  experiments  have  since  been  veri- 
fied by  many  observers,  foremost  among  them  Cornet,  Cohnheim, 
Tappeiner,  of  Germany;  Grancher,  Cornil,  Straus,  Verneuil, 
Chauveau,  and  Herard,  of  Franct  ;  Williams,  Clarke,  and  Wilson 
Fox,  of  England ;  Welsh,  Biggs,  Loomis,  Prudden,  Hodenpyl, 
and  Klebs,  of  the  United  States. 

On  the  24th  of  March,  1882,  Kocb  announced  to  the  world  his 
memorable  discovery  of  the  bacillus  tuberculosis — a  discovery 
which  shed  a  new  light  on  tuberculosis  as  a  disease  due  to  a  dis- 

■  J.  L.  SchSnlein's  "  Allgemeine  und  speciclle  I'atbologie  unci  Tlierapie. " 


INTEKESTINO    DATA    IN    THE    HISTORY   OF  TUIIERCULOSIS.  23 

tinct  micro-organism.'  Of  the  history  of  Koch's  next  most  im- 
portant communication,  concerning  the  tubercuhne,  made  on  tlie 
24th  of  August,  l8go,  before  the  International  Medical  Congress 
in  Berlin,  we  will  speak  under  the  respective  chapter,  treating  of 
culture  products. 

In  concluding  this  historical  sketch  I  only  desire  to  add  the 
short,  but  nevertheless  interesting,  history  of  sanatoria  for  con- 
sumptives. Special  hospitals  for  scrofulous  and  tuberculous  dis- 
eases were  first  founded  in  England.  The  oldest  of  all,  "The 
Royal  Sea-bathing  Infirmary  for  Scrofula,"  in  Kent  County,  is  still 
existing.  It  was  founded  in  179 1.  It  is  for  the  poor  only,  and 
admits  all  forms  of  tuberculosis  except  laryngeal  and  pulmonary. 
It  has  now  220  beds.  The  next  oldest  hospital  for  tuberculosis, 
and  the  first  exclusively  devoted  to  diseases  of  the  lungs,  is  the 
"  Royal  Hospital  for  Diseases  of  the  Chest,"  on  City  Road,  in 
London,  which  was  founded  in  1814.  It  now  accommodates  eighty 
patients.  "  Brompton  Hospital  for  Consumptives,"  the  most  im- 
portant of  the  English  institutions,  was  established  in  i84i,and 
has  now  321  beds.  Since  then  special  hospitals  have  multiplied 
in  England  in  greater  proportion  than  in  any  other  country. 
Sanatoria,  on  the  contrary,  are  still  relatively  rare  in  England, 
and  Germany  takes  the  lead  in  this  class  of  institutions. 

Perhaps  the  earliest  effort  in  sanatorium  treatment  was  inaugu- 
rated by  Dr.  George  Bodington,  of  Sutton  Coldfield,  Warwickshire, 
England.-  In  him  we  must  recognize  a  predecessor  of  Brehmer 
and  Dettvveiler,  for  in  his  "  Essay  on  the  Cure  of  Pulmonary  Con- 
sumption on  Principles  Natural,  Rational,  and  Successful  "  he 
advocates  a  generous  diet  consisting  of  fresh  meats,  eggs,  farina- 
ceous food,  beef-tea,  milk,  etc.,  and  insists  upon  fresh  air  day  and 
night.  Concerning  the  foundation  of  the  first  sanatorium  for  con- 
sumptives, in  1839,  which  very  nearly  approaches  the  conception  of 
the  German  "  Heilanstalt  "  of  to-day,  we  will  quote  his  own  words  : 
"  I  have  taken  for  the  purpose  a  house  in  every  respect  adapted, 
and  near  to  my  own  residence,  for  the  reception  of  patients  of  this 
class.    .    .    .    It  is  presumed  that  the  advantages  to  be  derived  from 


'  Robert  Koch,  "Die  Aetiologie  iler  Tuberkulose,"  "  Berliner  klin.  Wochenschrift," 
No.  15,  1882. 

^  "  Dr.  CJeorge  Bodington  (1840),"  by  A.  Tucker  Wise,  M.D.     ("  New  York  Med. 
Journal,"  vol.  l..\ix,  No.  2). 


24 


PULMONARY   TUDKKCULOSIS, 


systematic  arrarifjements  with  rejjarii  to  exercise,  diet,  and  genera) 
treatment,  with  the  watchfulness  daily,  nay,  almost  liourly,  over  a 
patient  of  a  medical  superintendent,  {jreat  advantages  may  be 
obtained  by  the  consumptive  patient  treated  in  tliis  way." 

The  founder  of  the  first  sanatorium  in  Germany  for  the  exclusive 
treatment  of  tuberculosis,  and  the  best-known  promulgator  of 
modern  phthisio-therapy,  was  Hermann  Urehmer,  of  Gorbersdorf. 
His  tliesis  for  the  final  degree,  published  in  1856,  is  characteristic 
of  his  life's  work  :  "  Tuberculosis  primis  instadiis  semper  curabilis." 
Hut  in  spite  of  his  efforts  he  could  not  get  the  autliorization  to 


I'Ui.    I.— Illl.    llKK.MASN    ItKKHMKR. 


open  an  establishment  for  the  exclusive  treatment  of  tuberculous 
patients.  His  democratic  ideas  were  not  favorably  looked  upon 
by  the  Prussian  government,  and  only  through  the  powerful  influ- 
ence of  his  distinguished  friends,  Humboldt  and  Schonlein,  he 
received  at  last,  in  1859,  the  authorization  to  open  his  sanatorium. 
Ikehmer's  work  and  example  has  born  good  fruits.  He  died 
December  22,  1889.  Dr.  lirehmer  was  a  striking  figure:  impos- 
ing, energetic,  with  a  beautiful  head  on  broad  shoulders,  and  a 
patriarchal  beard.  He  knew  how  to  inspire  his  patients  with 
implicit  confidence.  The  photograph  which  I  reproduce  here  is  a 
splendid    likeness  of   this    great   physician,      lirehmer  was   most 


INTEKESTINr,    DATA    IN   TIIK    HISTORY   OF   TUBKKCULOSIS. 


25 


fortunate  in  his  enterprise,  but  he  was  not  privileged  to  enjoy  the 
satisfaction  of  seeing  sanatoria  erected  all  over  the  world,  where 
his  precepts  for  the  treatment  of  consumption  would  he  eagerly 
followed.  His  most  distinguished  pupil  and  co-worker,  Geheim- 
rath  Dr.  Dettweiler,  has  somewhat  modified  lirehmer's  treatment, 
by  instituting  more  particularly  the  rest  cure.  He  is  still  at  the 
head  of  the  celebrated  institution  at  I'alkcnstciii.  Dr.  Dettweiler 
is  also  consulting  piiysician  for  the  first  German  sanatorium  for 
the  consumptive  poor  at  Ruppertshain,  which  was  founded  in  1S92. 

As  pioneers  in  .urotherapy  and  in  the  rational  treatment  of  pul- 
monary tuberculosis,  two  persons  shouUl  not  be  forgotten — Bennet, 
of  Menton,  an  English  physician,  himself  a  consumptive,  tried  on 
his  own  person  the  effects  of  a  permanent  outdoor  life,  under  the 
guidance  of  that  ingenious  and  world-famed  nurse,  Florence  Night- 
ingale. Iknnet  published  his  treatment  of  pulmonary  phthisis  by 
hygiene,  climate,  and  medicine  in  Paris,  1874;  a  book  which  is  still 
considered  a  mo.st  valuable  guide  in  the  treatment  of  pulmonary 
tuberculosis. 

The  history  of  sanatoria  for  the  poor  and  for  those  of  moderate 
m_ans  is  still  the  history  of  the  day.  Only  in  recent  years  have 
they  begun  to  multiply  in  various  countries.  To  the  United  States 
belongs  the  credit  of  having  erected  the  first  sanatorium  for  con- 
sumptives among  the  poorer  classes.  Some  fifteen  years  ago  Dr. 
E.  L.  Trudeau,  of  Saranac  Lake,  made  a  personal  appeal  for  con- 
tributions in  order  to  erect  a  cottage  sanatorium  in  the  Adirondack 
Mountains.  In  1884  a  small  cottage  and  the  wing  of  the  intended 
main  building  were  erected.  Each  year  the  institution  grew,  so 
that  it  now  has  some  eighteen  separate  cottages,  and  can  accom- 
modate nearly  one  hundred  patients.  It  owes  its  prosperity  mainly 
to  the  personal  efforts  of  its  founder  and  his  friend,  the  late  Pro- 
fessor Alfred  Loomis,  of  New  York,  and  to  the  generosity  of  the 
public.  . 

As  of  historical  interest  in  modern  phthisio-therapy  we  must 
mention  the  inauguration  of  the  first  l^i-annual  Congress  for  the 
Study  of  Tuberculosis  in  Paris,  in  1888,  under  the  presidency  of 
Professor  Chauveau.  Lastly,  I  desire  to  note  two  literary  events 
connected  with  our  subject:  In  1893  appeared  the  first  number  of 
that  excellent  journal,  "  La  Revue  de  la  Tuberculose,"  under  the 
direction  of  the  late  Professos  Verneuil,  with  Jiouchard,  Chauveau, 
Brouardel,   Charcot,  Cornil,    A.    Fournier,   J.    Grancher,   Lanne- 


BHOHiiHi 


t,l 


fii 


26 


PULMONARY   TUBERCULOSIS. 


■  T' 


lonffne,  Nc.ard,  Potain,  Richet,  I.  Straus,  Tarnier,  and  L.  H.  Petit 
as  co-editors.  On  the  1st  of  January,  1897,  appeared  in  Berlin, 
under  the  direction  of  Dr.  Gotthold  Pannwitz,  the  first  issue  of  that 
interesting  little  journal  called  the  "  Heilstatten  Korrespondenz.' 
It  is  the  organ  of  the  German  Central  Committee  for  the  Foundation 
of  Sanatoria  for  the  Consumptive  Poor,  and  contains  all  the  latest 
news  appertaining  to  the  subject.  Lastly,  on  February  15,  1898, 
the  first  number  of  "  La  Tuberculose  Infantile  "  appeared.  It  is  a 
bright,  interesting  bi-monthly  journal,  devoted  to  tuberculous 
diseases  of  childhood ;  edited  under  the  direction  of  Drs.  Leon 
Derecq  and  Georges  Petit,  of  Paris. 


CHAPTER  II. 
MORTALITY  FROM  PULMONARY  TUBERCULOSIS. 


'  Miyiarov  5e   Kai.   ;^aAen-iilTaTo»'    Kal    irAeiVou?  iKTfLve   to  tftdivuSti.^'      "  The    greatest    and   niORt 
dangerous  disease,  and  the  one  that  proved   fatal  to  the  greatest  number,  was  con- 
sumption."—(Hippocrates,  "  Epidemics,"  iii,  Sec.  3, 13,   Adam's  translation.) 


We  see  from  the  above  quotation  that  even  at  the  times  ot 
Hippocrates  the  mortaUty  from  pulmonary  tuberculosis  was 
already  alarmingly  great.  To-day  it  is  generally  conceded  that 
one-seventh  of  all  deaths  are  due  to  consumption,  and  that  one- 
sixth  of  all  mankind  is  tuberculous. 

The  following  statistical  table  is  the  latest  I  could  obtain.  It 
gives  the  mortality  from  pulmonary  tuberculosis  for  each  thousand 
individuals  living.  It  appeared  in  the  "  Miinchener  med.  Wochen- 
schrift "  of  January  7,  1896,  and  seems  to  be  most  carefully  com- 
piled : 


Cities. 

Population. 

1894. 

Francf.: 

Le  Havre, • 

Rouen       

1 16,000 
111,000 
2,424,000 
86,000 
431,000 
105,000 
122,000 
I'S.coo 

70,  OX) 

252,000 
131,000 
406,000 
148,000 

83,000 

65,000 
161,000 
361,000 

8i,ooo 

50.3 
450 
41.6 

33-7 
33.6 
32.6 
30.1 

m 

25-S 

23s 
21.8 

17.7 
16.5 

52.4 
39-3 
34-9 
33.S 

Paris 

Nan<:) 

Lyon 

Keims, 

Nantes, 

Roubaix, 

Lille 

Bordeaux, 

SaintEtienne, 

Marseille 

Toulouse,      

Alger 

Gr.RMANV  : 

WUrzburg 

Nuremberg,      

Breslau,     .    .        

Augsburg 

27 


I  ^i 


28 


PULMONARY   TUBERCULOSIS. 


Cities. 


Germany — Con  tin  ued. 
Munich,  .... 
Cologne,  .... 
Frankfort,  .  .  . 
Elberfeld,  .  .  . 
Dresden,  .... 
Altona,  .... 
Leipzig,  .  . 
(iiirlitz,  .... 
Chemnitz,     .    . 

Herlin, 

Hamburg,     .    .    . 
Liibeck,    .... 

In  Other  Countries 
liudapest, 
Vienna,     .... 
St.  Petersburg, 
Moscow,   .... 
Warsaw,   .... 
New  York,   .    .    . 
Philadelphia,    .    . 
(llasgow,       ,    .    . 
Naples,     .... 
Buenos-.Vyres, 
Manchester,      .    . 

London 

Chicago,    .... 


Population. 


393.000 
309,000 
201,000 
138,000 
316,000 
149,000 
404,000 

67,000 

150,000 

1,703,000 

604,000 

69,000 


552,000 

1,465,000 

954,000 

753,000 

500,000 

1,925,000 

1,115 .000 

686,000 

535,000 

580,000 

522,000 

5,300,000 

1,600,000 


1894. 


30.8 
28.2 
27.2 
26.6 
26.0 

24.7 
24.0 

24-3 
22.7 
22.3 
21.1 
16.1 


49-3 
45-4 

44-3 
42.9 

25-7 
24.1 

23.7 
22.6 
21. 1 

20.7 
19.6 

17-3 
134 


For  the  United  States  it  seems  to  me  of  interest  to  give  the 
statistics  of  each  State,  as  reproduced  in  Polk's  "  Medical  and 
Surgical  Regi.ster  for  1898": 


Stat  I 


Alabama,  .... 
Alaska.* 

Arizona 

Arkansas,  .... 
California,  .... 
Colorado,  .... 
Connecticut,  .  . 
Delaware,  .  .  . 
District  of  Columbia, 

Florida, 

Georgia, 

Llalio,      

Illinois,    . 

'   dian  Territory,* 


Total  Ni'Mbkr 

DF.ATH-RATE 

Dbaths  from 

OF  Dkaths  from 

FROM   CONSUMP- 

Consumption  pi- 

R 

Consimption 

TID.N    IM-.R    1000    OF 

looo  of  Total 

DiRr.NG  1890. 

Population. 

Dkaths. 

2163 

1-43 

103.50 

68 

1. 14 

I1S.67 

1209 

1.07 

8401 

28K() 

2.39 

163.19 

4X9 

1. 18 

89.68 

1743 

2.34 

120.46 

476 

2.83 

153-20 

827 

359 

138.87 

377 

0. 96 

90.9s 

2155 

1. 17 

101.77 

36 

0.43 

46. 69 

5698 

1.49 

107.26 

*  No  reliable  mortality  statlsticB  are  obtainable. 


MORTALITY   FROM    PULMONARY   TUBERCULOSIS. 


29 


1894. 


State. 


30.8 
28.2 
27.2 
26.6 
26.0 

24.7 
24.0 

243 
22.7 

22-3 
21. 1 
16.  I 


49-3 
45-4 
44-3 
42.9 

25-7 
24.1 

23-7 
22.6 
21. 1 
20.7 
19.6 

17-3 
134 


to  give  the 
Medical  and 


Dkaths  from 
iinsimftion   i'kr 

1000   OI-    TOTAI. 

Deaths. 


103.50 

I1S.67 
84  01 

89.68 

120.46 

153-20 

138.87 

90-95 
101.77 

46. 69 
107.26 


Indiana,  .    ,    .    . 

Iowa 

Kansas,  .  .  .  . 
Kentucky,  .  .  . 
Louisiana,  .  .  . 
Maine,  .  .  .  . 
Maryland,  .  .  . 
Massachusetts,  . 
Miciiigan,  .  .  . 
Minnesota,  .  .  . 
Mississippi,  ,  . 
Missouri,  .  .  . 
Montana,  .  .  . 
Nebraska,  .  .  . 
Nevada,  .  .  . 
New  Hampshire, 
New  Jersey,  .  . 
New  York,  .  . 
North  Carolina, 
North  Dakota,    . 

Ohio 

Oklahoma,  .  .  . 
Oregon,  .  .  .  . 
Pennsylvania, 
Rhode  Island,  . 
South  Carolina,  . 
South  Dakota,  . 
Tennessee,  .  .  . 
Texas,      .    .    .    . 

Utah 

Vermont,  .  .  . 
Virjjinia,  .  .  .  . 
Washington,  .  . 
West  Virginia,  . 
Wisconsin,  .  .  . 
Wyoming,    . 


Total  Ni'MBER 

Death-rate 

Deaths  from 

uF  Ukaths  from 

FRO.M   CONSI'MP- 

CONSIMFTION    PER 

Co.nsl'.mption 

TION   PER    1000  OF 

1000  OK  Total 

Dt'Ri.N';  1890. 

POPL'LATION. 

Deaths. 

3504 

1.60 

144.91 

1832 

0.96 

104.56 

1368 

0.96 

i'3-83 

353S 

1.90 

148.  IS 

ISI6 

1-35 

92.70 

1477 

2.23 

147-05 

23»S 

2.22 

128.61 

5981 

2.67 

132.58 

2747 

'•31 

109.81 

1532 

1.17 

98. 92 

1433 

MI 

96.18 

3559 

1-32 

109.72 

55 

0.42 

54.34 

604 

0.57 

71-52 

35 

0.77 

80.65 

729 

1-93 

103.05 

3388 

2-34 

112.65 

14.854 

2.47 

120.65 

2212 

1-37 

112.00 

167 

0.91 

9732 

6393 

1-74 

128.26 

21 

0.34 

59.66 

305 

0.97 

118.45 

7689 

1.46 

104-57 

921 

2.67 

121.84 

2112 

1-83 

136.30 

208 

0.63 

76.89 

3637 

2.06 

152.47 

2059 

0.92 

77-93 

62 

0.30 

29.26 

601 

1. 09 

121.84 

3050 

1.84 

131.28 

278 

0.79 

103.15 

"43 

1.50 

138-13 

2015 

1. 19 

107.97 

18 

0.30 

43-48 

Concerning  the  relative  mortality  from  the  various  diseases,  I 
give  here  Professor  Fletcher  VV.  Heues'  interesting  dial,  as  it 
appeared  in  Cuzner's  article  in  "  The  Journal  of  the  American 
Medical  Association,"  of  December  17,  1898. 

This  dial  shows  the  terrible  mortality  from  diseases  of  the 
respiratory  organs,  and  especially  from  pulmonary  consumption. 

We  will  learn  in  chapter  vii,  on  the  Care  of  Consumptives  by 
the  Authorities,  how  much  the  mortality  has  already  been  decreased 
in  these  latter  years  in  some  of  the  cities  of  Europe,  thanks  to  the 
creation  of  special  hospitals  and  sanatoria  for  the  poorer  clas.ses, 
and  also  in  a  few  cities  in  the  United  States  by  the  inauguration  of 


r  !i! 


30 


PULMONARY  TUBEKCULOSIS. 


a  rigorous  prophylaxis  against  the  spread  of  tuberculosis.     How- 
ever, we  shall  also  see  how  much  is  yet  to  be  done  in  the  line  of 


1  ^'^  eoo 


I'lG.   2. 


prophylaxis  and  in  the  creation  of  special  institutions  in  order  to 
combat  the  spread  of  this  disease  more  effectually  everywhere. 


:     y 


n 


CHAPTER  III. 

PATHOLOGICAL   PROOFS   OF   THE    CURABILITY   OF 
PULMONARY  TUBERCULOSIS. 


The  curability  of  pulmonary  tuberculosis  in  the  first  and  second 
stage  is  yet  much  contested,  even  by  medical  men.  Among  the 
laity  the  belief  that,  the  disease  once  declared  to  be  present,  all 
hope  has  to  be  abandoned,  is  still  very  prevalent.  To  convince 
the  patient  of  the  contrary,  to  instil  in  him  the  hope  of  recovery, 
to  encourage  him  in  his  persistent  effort  to  carry  out  all  the  details 
which  tend  to  improve  his  condition,  should  constitute  an  impor- 
tant part  of  the  educational  treatment  of  all  consumptives.  Doubt- 
ing physicians  should  go  into  the  dissecting-room  and  witness  the 
coroner's  post-mortem  examinations.  They  will  see  many  a 
cicatrized  lung  lesion  in  persons  who  have  died  from  entirely 
different  diseases  or  from  accidents.  As  early  as  1838  Carswell  ' 
wrote :  "  Pathological  anatomy  has  perhaps  never  given  more 
decisive  proofs  of  the  curability  of  a  disease  than  it  has  given  for 
pulmonary  consumption."  These  words  from  one  of  the  foremost 
pathologists  of  his  time  may  be  recalled  to  doubters  as  an  evidence 
of  how  wrong  they  are  in  their  pessimistic  conception  of  a  disease 
which  is  eminently  curable.  By  personal  inquiry,  through  letters 
addressed  to  the  leading  pathologists  of  the  world,  and  by  looking 
up  the  literature  on  the  subject,  I  have  myself  compiled  some 
statistics  giving  the  pathological  proofs  of  the  curability  of  pul- 
monary tuberculosis,  from  which  I  append  the  table  on  next  page. 

Besides  those  mentioned  in  the  table,  Andral,  Meckel,  Roki- 
tanski,  Ulsperger,  Virchow,  and  Werdmiiller"  have  reported  cases 
of  healed  tuberculous  lesions  in  persons  who  had  died  of  other 
than  tuberculous  diseases.  Laennec^  believed  in  the  curability 
of  pulmonary  tuberculosi.s.     Curveilhier,   in   his  "  Traite   d'Ana- 

'  Carswell,  "  Pathological  .Xnalomy,"  London,  1838. 

'  P.  Mnnasse's  statistics  in  his  "  lleilun<;  tier  I.uiigentuberkulose." 

•  Laennec,  "Traite  tie  I'auscultation  imjiliate."     Kdilion  ile  la  Faculti;,  1S79. 

31 


32 


PULMONARY   TUBERCULOSIS. 


1(1 1 


!l 


Reportro  by. 

Nl'.MBER 
OF 

Autopsies. 

Number  ok  Cases 

WMKKE  Autopsy  Kevkai.eo 

Healed  Pulmonary 

Tuberculous  Lesions. 

lioudet,  of  Paris, 

Heaux,  of  Paris 

liennet,  of  Menton, 

Uaudet,  of  Paris 

Marsini,  of  Basel, 

Bollinger,  of  Munich,    ...        

135 
1 66 

73 

III 

400 
16,562 
701 
670 
763 
189 

'31 

1.943 
445 
103 

116 

157 
28 
10 

89 
69 

789 
78 

75 
71 
92 
29 
SO 
17 
177 
42 
25 

51     percent. 
27       "     " 

39      "     " 
10      "     " 

Heitler,  of  Vienna,    ...            

Chiari,  of  Prague,                   

Flint,  of  New  York. 

Loomis,'  of  New  Vork, 

Letulle,  of  Paris 

F.  P.  Weber,  of  l^ndon 

Ormerotli,  of  London,  ....                ... 

Vilbert,  of  Paris, 

Fowler,  of  London, 

Martin,  of  London, 

Jos.  Coats,  of  Glasgow,     .    . 

Rogee,  of  Paris, 

Standacher, 

Thomas  Harris,  of  London,         

Furl>ringer,  of  Berlin, 

Renvers,  of  Berlin, .    . 

Bugge,  of  Christiania ,    . 

Osier,  of  lialtinjore 

30      "     " 
27       '•     " 

7-5   "     " 

4      "     " 

30      "     " 

Walker,  of  Chicago 

H.  M.  Biggs,  of  New  York, 

'  Loomis,  H.  ['.,  "  A  Study  of  the  Processes  which  Result  in  the  .\rrisl  or  Cure  of  Phthisis." 
"  Medical  Record,"  J.in.  9.  1892. 

tomie  generale,"  vol.  iv,  page  538,  declares  tuberculosis  a  de- 
cidedly curable  disease,  and  so  does  Charcot,'  in  his  "Traite 
de  Medecine,"  by  saying:  "Phthisis  is  susceptible  to  be  cured 
completely  and  definitely  even  at  the  period  of  cavities."  Gran- 
cher,  in  his  "  Lemons  cliniqii<.5  sur  les  Maladies  de  I'Appareil 
respiratoire,"  1880,  page  245,  says  :  "  We  affirm  the  curability 
of  the  tubercle;  we  affirm  that,  instead  of  being  a  miserable 
neoplasm  incapable  of  organization,  the  tubercle  tends  naturally 
to  fibrous  formation."  Jaccoud"  even  maintains  that  pulmonary 
phthisis  is  curable  in  all  its  stages.  Herard  and  Cornil  '  are  of  the 
same  opinion.  Professor  l^ouchard,of  Paris,  concluded  his  lectures 
on  phthisis  in  the  year   1888  by  the  following  comforting  words : 

'  Charcot,  "  'I'raiti  de  Mddecine  de  Charcot  at  Bouchard";  aiticle,  Phtisie  pulmon- 
aire. 

2  Jaccoud,  "  Curabilite  de  la  Phtisie  pulnionaire,"  l8S8. 
^  Herard,  Cornil  et  ilanot,  "  La  Phtisie  pulinonaire,"  iSSS. 


m 


Cine  of  Plilhisis." 


e,  I'htisie  pulmon- 


PROOFS   OF   THE   CURABILITY   OF    PULMONARY   TUBERCULOSIS.       33 

"  This  disease,  which  has  such  a  strong  hold  on  humanity,  is 
curable  in  the  largest  number  of  cases."  Of  the  striking  and 
interesting  answers  I  received  to  my  letters,  or  to  personal  in- 
quiries, I  desire  yet  to  cite  the  following:  Dr.  Brouardel,  Dean  and 
Professor  of  Legal  Medicine  at  the  Faculty  of  Medicine  of  Paris, 
said  to  me  :  "There  is  hardly  any  autopsy  performed  at  the  morgue, 
of  persons  having  died  an  unnatural  death,  where  healed  tuberculous 
lesions,  cicatrized  and  calcified,  are  not  found;  especially  if  the 
individual  has  lived  more  than  ten  years  in  Paris."  Professor  Fritz 
Strassmann,  of  Berlin,  expressed  himself  as  follows:  "  I  have  very 
often  found  old  foci  of  pulmonary  tuberculosis,  cicatrized  and  cal- 
cified, in  individuals  who  had  died  by  accident."  Prof.  James 
Goodhart,  Physician  of  Guy's  Hospital  of  London,  wrote  me:  "I 
am  able  to  say  that  there  is  nothing  more  common  than  to  find  in 
those  dead  from  other  causes  evidences  of  old  and  healed  phthisis 
or  calcareous  changes  in  the  various  glands ;  moreover,  in  most 
cases  of  tubercular  disease  there  is  similar  evidence  that  a  former 
disease  of  this  kind  has  healed.  I  am,  therefore,  accustomed  to  say 
that  there  is  no  disease  that  gives  stronger  evidence  of  healing 
tendencies  than  phthisis."  In  connection  with  the  preceding  state- 
ment, Hermann  Weber's  remarkable  case  of  a  twice-healed  tuber- 
culosis may  be  cited.'  This  case  was  first  diagnosed  in  1867  as 
pulmonary  tuberculosis.  A  hzemophthisis  was  the  cause  of  the 
patient  consulting  Dr.  Weber.  The  patient  was  completely  cured 
after  several  months  of  judicious  hygienic,  dietetic,  and  climatic 
treatment.  In  1873,  after  a  year's  residence  in  Paris  and  London, 
he  was  again  seized  with  a  ha^mophthisis.  While  in  the  first  attack 
the  left  side  was  involved  and  the  right  side  was  free,  this  time  it 
was  the  right  side  which  presented  the  dullness,  with  crepitant 
rhonchus  down  to  the  fourth  rib,  the  condition  in  which  the  left 
side  had  been  in  1867.  The  left  side  at  the  time  of  the  second 
attack  had  remained  free,  showing  only  a  slight  dullness.  Again 
outdoor  life  and  judicious  hygiene  and  diet  cured  the  patient.  In 
1881  Dr.  Weber  saw  him  again,  the  patient  being  ill  with  well- 
developed  typhoid  fever  of  a  moderate  type,  without  any  lung 
complication.  He  had  almost  recovered,  when,  at  the  end  of  the 
fourth  week  of  the  disease,  he  committed,  against  strict  advice,  the 

'  Weber,     "  Hygienische    uml    klimatische   liehandlung   (k-r    clironisclien   Lungen- 
schwindsucht." 
3 


mmu 


m 


34 


PULMONARY   TUUKRCULOSIS. 


imprudence  of  eating  a  rather  large  quantity  of  grapes,  and  died 
of  a  perforation  of  the  lower  part  of  the  ileum.  At  the  post 
mortem  examination  there  were  cretaceous  patches  in  the  apices  of 
both  lungs,  and  also  in  the  lower  lobe  of  the  right  lung. 

Dr.  Whittacker,  of  Cincinnati,  said,  in  answer  to  my  inquiry  : 
"  It  is  a  great  exception  to  find  upon  the  post  mortem  table  a  pair 
of  lungs  totally  free  from  some  evidence  of  existing  or  preexisting 
tuberculosis."  Dr.  Nicholas,  Physician-in-Chief  of  the  Hospital  of 
Neuchatel,  in  Switzerland,  very  kindly  responded  to  my  letter  by 
saying:  "It  has  happened  to  me  repeatedly  to  find  at  autopsies 
cicatricial  tissue,  with  and  without  calcareous  foci,  in  the  apices  of 
the  lungs;  but  owing  to  a  lack  of  special  notes  I  am  unable  to  give 
you  the  exact  proportions." 

While  we  must  admit  that  at  times  these  foci  represent  only  the 
tuberculosis  which  has  become  latent,  whenever  the  fibrinous  or 
calcareous  transformation  of  the  tubercles  is  complete  these  latter 
are  no  longer  virulent.  Kurbow  '  was  able  to  demonstrate  by 
inoculation  that  out  of  one  hundred  cases  of  seemingly  latent 
tuberculosis,  in  twenty-seven  the  tubercles  had  entirely  lost  their 
infectious  qualities.  Dejerine,^  who  made  similar  investigations, 
examined  a  very  large  number  of  such  old  localized  calcareous* 
foci,  and  in  not  one  instance  could  he  discover  the  presence  of  the 
tubei   le  bacillus. 

Ot  the  clinical  evidences  of  the  curability  of  pulmonary  tuber- 
culosis, and  the  results  obtained  in  special  sanatoria,  I  will  .speak  in 
the  concluding  chapter. 


'  Kurbow,  "Arch,  fiirklin.  Mediciii,"  1889,  vol.  xi.lv,  fas.  5-6. 

'  D^jerine,  "  Recherche  du  bacillc  de  Koch,"  "  Conii)l.  reii<l.  Iiebil.,''  KS.S4,  Xo.  30. 


CHAPIER    IV. 

THE     COMMUNICABILITY     OF     PULMONARY     TUBERCU- 
LOSIS, AND  THE  MEANS  TO  COMBAT  ITS   PROP- 
AGATION  BY   INDIVIDUAL   PROPHYLAXIS. 

It  is  now  generally  conceded  that  the  cause  of  tuberculosis  in 
man  or  beast  is  the  bacillus  tuberculosis,  discovered  by  Robert 
Koch'  in  1882.  Without  the  presence  of  this  germ  there  is  no 
tuberculosis. 

The  bacillus  enters  the  human  system  through  either  the  respi- 
ratory or  the  digestive  tract ;  it  may,  however,  also  enter  through 
the  cutaneous  system,  though  much  more  rarely,  when  there  is  an 
abrasion  of  the  skin  which  makes  the  inoculation  of  the  germ 
possible. 

The  two  most  important  methods  whereby  man  contracts  tuber- 
culosis— inhalation  and  ingestion — seem  to  be  equally  frequent. 
We  will  first  consider  the  inhalation  process. 


.'•  1884,  Xo.  }o. 


INFECTION   BY   INHALATION. 

An  individual  suffering  from  pulmonary  tuberculosis  is  estimated 
to  expectorate  as  many  as  seven  billions  of  bacilli  in  twenty-four 
hours.     This  patient  may  not  be  sick  enough  to  be  in  bed ;  in 
fact,  the  patient  in  bed  is  perhaps  less  a  danger  to  his  fellow-men, 
for,  if  he  is  careless,  he  must  confine  his  unsanitary  habits  to  one 
room,  while  the  unscrupulous  or  ignorant  consumptive  still  able^^j^.^, 
to  be  about  disseminates  the  germs  of  his  disease  wherever  he^"/*^,';'"'^^'"'* 
goes.     As  long  as  the  expectorations  remain  in  the  liquid  state JJ[7i'ise'aseI^ 
there  is  less  danger  from  them,  but  matter  expectorated  on  the 
floor,  in  the  street,  or  in  a  handkerchief  usually  dries  very  rapidly, 
and,  becoming  pulverized,  finds  its  way  into  the  respiratory  tract 
of  any  one  who  chances  to  inhale  the  air  in  which  is  floating  this 

'  Robert   Koch,    "  Die    Aetiologie   der   'I'uberkulose,''    "  Herliiier   klin.    Woclien- 
schiilt,"  No.  15,  1S82. 

35 


-I 

i 


T 


iiii 


36 


I'ULMONAKY  TUBERCULOSIS. 


dust  from  expectorcitions,  laden  witli  many  kinds  of  bacteria.' 
The  most  dangerous  of  tliem  all  is  the  tubercle  bacillus,  which 
retains  its  virulence  in  the  dried  state  for  several  months.'- 

If  an  individual  is  perfectly  well,  the  inhalation  of  the  bacilli  will 
not  hurt  him.  In  health  the  nasal  mucous  secretion  possesses 
bactericidal  qualities;''  but  if  anyone  with  a  weak' ned  constitution 
or  a  particular  predisposition  to  consumption  should  be  exposed 
to  the  inhalation  of  particles  of  dried  and  pulverized  tuberculous 
expectoration,  he  would  certainly  be  in  the  very  greatest  danger  of 
thus  contracting  pulmonary  tuberculosis.  Countless  are  the  cases 
reported  which  prove  beyond  a  doubt  this  mode  of  propagation  of 
the  disease.  In  addition,  tuberculosis  has  been  produced  by  this 
method  experimentally  in  the  lower  animals.  The  writings  and 
experimental  work  of  Villemin,^  Weber,'  Koch,"  Tappeiner,"  Cor- 
net," Kriiger,'-'  Straus,'"  Hance,"  Murreil,'-'  etc.,  all  confirm  what 
has  just  been  said  on  the  danger  from  the  careless  and  promiscuous 
e.xpectorating  of  tuberculous  individuals.  My  own  inve.stigations 
in  this  respect  show  that  what  is  proved  experimentally  and  clini- 


'  Straus,  "  Sur  la  [iresL'tice  'lii  hacille  de  la  tiiberculose  ilaiis  les  cavilus  tiasales  de 
riiomnie  sain,"  "  Uulletiii  de  rAcadumie  de  Medecine  de  I'aris,"  1S94,  Seanc<'  du  3 
juillet. 

^  Sawitzky,  "  Zur  Frage  iiber  die  Dauer  der  infcclioben  Kigtnschafleii  des  jjetrock- 
neten  tuberkulosen  Sputums."  Dissert,  inaug.,  St.  I'etersbiirg,  1S91,  and  "  Contral- 
blatt  fiir  Hactericilot;ie,"  lid.  XI,  I.S92. 

'  Wnrtz  et  Lermoyez,  "  Du  rOle  bactericide  du  mucus  nasal,"  "  Compte  rendu  de  la 
Soc.  de  Biol.,"  1893,  p.  756. 

■•  V'illemin,  "  De  la  I'rophylaxie  de  la  I'litisie  I'ulmonaire,"  "  Union  Mcdicale," 
1S68,  p.  150. 

*  Weber,  "On  the  Coininunicabilily  of  Consumption  from  Husband  to  Wife," 
"  Clinical  Socitty's  Transactions,"  1874,  vol.  vil,  p.  144. 

"  Koch,  "  Die  Aetiologie  der  Tulwrkulose,"  "  Mittheilungen  a.  d.  k.  (iesundheits- 
amte,"  Bd.  u,  1884,  p.  79. 

"  Tappeiner,  "  Ueber  eine  Methode  Tuberkulose  zu  erzeugen,"  "  Virchow's  Arch.," 
1878,  Bd.  I.x.\iv,  p.  393. 

*  Cornet,  "  Die  Verbreitung  der  Tuberkelbacillen  ausserhalb  des  KSrpers,"  "  Zeit- 
schrift  f.  Hyg.,"  1888,  Bd.  v,  pp.  191-332. 

"Kriiger,  "  Einige  Untersucliungen  des  Staubniedersclilages  der  I.uft  in  Bezug  auf 
Tuberkelbacillen,"   Dissert,  inaug.,  Bonn,  1X89. 

'"Straus,  "  La  Tuberculose  etson  Bacille,"   I'aris,  1895. 

'Mlance,  "  A  Study  of  the  Infectiousness  of  the  Du.st  in  the  Adirondack  Cottage 
Sanitarium,"  "  N.  Y.  Med.  Recor<l,"  Dec.  28,  1805. 

"  Murrell,  "  Lancet,"  April  10,  1897,  p.  I018. 


COMMUNICAUILITV    OK   PULMONARY    TUHKRCULOSIS. 


37 


lactena." 
s,  which 

iicilli  will 

possesses 

istitution 

exposed 

lerculous 

danger  of 

the  cases 

igation  of 

d  by  this 

itings  and 

ner,"  Cor- 

ifirni  what 

omiscuous 

estigations 

and  clini- 

tiis  iiasales  de 
,  S6anc<-  du  3 

11  des  t^etrock- 
and  "Onlral- 

jilc  lendu  de  la 

ion    Modicale," 

laiid   10   Wife,"' 

k.  Ciesundheits- 

rclK)\v"s  Arch," 

Orpers,"  "  Zeit- 

,uft  in  Bezug  auf 

rondack  Cottage 


cally  to  be  possible  does  occur  on  a  large  scale.     In  visiting  many  spread 
of  the  so-called  Iteaith  resorts  especially  frequented  by  pulmonary  i<>sis   n 

.    '  _   '  ^  /  \  .  •'   healll.  11.- 

invalids,  I  have  seen  these  patients,  in  all  stages  of  the  disease, s"ri»- 
promenading  and  expectorating  everywhere,  and  I  became  con- 
vinced that  they  were  thus  disseminating  their  disease  among  the 
permanent  inhabitants  of  that  region.  I  addressed  the  proper 
authorities  in  these  resorts  for  information,  and  I  will  reproduce 
here  the  answers  of  two  of  them.  The  chief  health  officer  of 
Nice,  Dr.  Ballestre,  wrote:  "II  e.st  de  notoricte  publiqiie  que 
Nice,  et  surtout  Menton,  ont  vii  augmenter  dans  une  i)roportion 
enorme  le  nombre  de  leurs  tiiberculeu.x  depuis  que  les  phtisiques 
ont  frequente  ces  stations."  ("  It  is  a  well-known  fact  that  Nice, 
and  especially  Menton,  have  seen  the  numberof  their  consiimj)tives 
increased  in  an  enormous  proportion  since  phthisical  patients  have 
frequented  these  resorts.") 

The  Secretary  of  the  New  Mexico  Territorial  Board  of  Health, 
Dr.  F.  H.  Atkins,  wrote  me  as  follows:  "  Like  other  communities 
much  resorted  to  by  consumjitives,  we  are  year  after  year  discover- 
\x\g  cases  of  phthisis  occurring  in  New  Mexico  among  people  born 
here,  or  quite  recently  come  here  and  healthy,  and  in  many  of 
them  there  has  been  a  definite  exposure  to  the  infection  of  the 
tubercle  bacillus." 

To  stop  the  spread  of  tuberculosis  by  the  careless  or  ignorant 
consumptive  we  must  begin  by  convincing  him  of  the  wrong  he  is 
doing  to  himself  and  others  by  the  manner  in  which  he  disposes 
of  his  infectious  expectoration.  The  danger  of  his  becoming 
continually  reinfected  must  be  particularly  impressed  upon  him. 
Such  a  [)atient  should  be  taught  never  to  expectorate  except  in 
a  proper  receptacle.  The  habit  of  expectorating  in  a  handker- 
chief should  be  considered  as  dangerous  as  expectorating  on  the 
ground,  for  the  frequent  unfolding  of  a  handkerchief  containing 
the  dried  sputum  is  a  most  common  way  of  disseminating  the 
bacilli,  and,  besides,  not  infrequently  the  patient  reinfects  thus  his 
upper  air-passages.  The  frequent  coexistence  of  pharyngeal  and 
laryngeal  tuberculosis  with  relatively  little  advanced  pulmonary 
lesions  may  well  be  explained  by  this  mode  of  secondary  infection. 

In  all  places  where  there  are  likely  to  be  tuberculous  patients, 
able  to  be  about,  whether  in  private  residences,  workshops,  offices, 
hospitals,  or  sanatoria,  there  should  be  the  proper  kind  of  spittoons, 
and  a  sufficient  number  of  them,  properly  placed  and  kept.     Cus- 


W 


i 


38 


PULMONAKY    TUHEKCULOSIS. 


I 


DaiiKer       pidors  placed  on  the  ground  should  be  done  away  with,  for  wliilc  a 

from  ciis-      r    ■  t  c  \  •  •         t  •  • 

pidors        fair  number  of  male  patients  may  possess  a  certain  df'xterity  in 

placot  oil  .  r,.  ..  r       t 

the gromui.  disposing  of  their  sputum,  I  have  yet  to  find  a  woman  who  knows 
how  to  hit  the  spittoon.     Where  much  expectoration  is  going  on, 


I'lr,.  4. 


KiG.  4'. 


FlCS.    3    AND    4.— SlMTIOOS,  El.KVATKD   TMRKK    I'KKT    OR     TMHKK    FKKT   SlX    I.NCIIKS   IROM    IHK 
Fl.DOR,  AND    INCLOSKI)    IN    IlIK   WaI.I.. 

I'"igs.  3  and  3',  plan  ;  4  and  4',  elevation.  ^  and  4  represent  the  door  closeil  ;  3'  and  4',  llie  door 
open.  A.  Frame.  B.  Cover.  C.  Spittoon.  P.  Uoor.  S.  Hinyed  support.  L.  Linoleum 
cover. 

one  usually  finds  the  brims  of  the  cuspidors  that  are  placed  on  the 
floor  covered  with  dried  sputa,  and  even  the  piece  of  oilcloth 
placed  underneath  as  a  precautionary  measure  often  shows  signs  of 
the  inexperienced  spitter.     To  obviate  these  difficulties,  and  still 


COMMUNICABILITY   OK    PULMONAKY   TUBKRCULOSIS. 


39 


ICllKS   FROM  TIIK 


make  the  presence  of  numerous  cuspidors  in  eitlier  private  dwell- 
injj,  hospital,  or  sanatorium  as  little  objectionable  as  possible,  I 
have  devised  an  arrangement  of  elevated  spittoons,  visible  only 
when  in  use.  In  the  walls  of  parlors,  halls,  galleries,  etc.,  at 
appropriate  distances,  arc  constructed  small  niches  or  cupboards 
3  or  3 1/2  feet  from  the  floor.  They  are  larjje  enough  to  hold  a 
spittoon  eight  inches  high  and  about  the  .same  diameter.  Not  to 
expose  the  persons  intrusted  with  cleaning  these  vessels  to  the 
|)()ssible  danger  of  inoculation  by 
breakage  of  porcelain,  I  prefer 
metal  spittoons,  lilue  enameled 
iron  seems  to  be  the  most  prac- 
tical of  all.  The  dark-blue  color 
makes  the  contents  less  visible. 
The  cuspidor  is  supported  by  a 
metal  ring  attached  to  the  door  of 
the  cupboard.  The  patient  desir- 
ing to  e.xpectoratc  opens  the  little 
door,  thus  bringing  the  spittoon 
within  his  reach,  and  closes  it 
again  when  he  gets  through.  An 
autonuttically  closing  extra  cover 
makes  it  impossible  for  flies  or 
other  insects  to  sojourn  in  the 
interior. 

The  drawing  will  more  fully 
explain  the  construction  and  the 
worlring  of  this  arrangement.  In 
the  grounds  surrounding  the  hos- 
pital or  sanatorium  the  niches  may 
be  rejjlaced  by  boxes  mounted  on 
stands  (see  Fig.  5)  or  attached  to  the  trunks  of  trees.  The 
cuspidor  of  metal,  elevated  and  covered,  has  additional  advan- 
tages over  the  usual  uncovered  vessel  of  porcelain  or  earthenware. 
Animals,  such  as  cats,  dogs,  etc.,  will  not  be  able  to  reach  the  contents 
of  the  cuspidor ;  and  there  is  less  danger  of  its  bursting  when  placed 
outdoors  at  freezing  temperature  if  covered  and  inclosed  in  a  box. 
In  the  grounds  of  in.stitutions  where  porcelain  vessels  have  been 
placed  it  has  happened  that  the  frost  cracked  the  spittoons  and 
caused  their  contents  to  be  spread  over  the  ground.     Now,  it  is  well 


5— Ki.KVA  ii;i>  Stand  ior  Simttdon. 


40 


PULMONARY    TUBERCULOSIS. 


[i  I 


>    n 


m 


Flies   may 

transmit 

bacilli. 


known  that  the  tubercle  bacillus  does  not  die  at  the  freezing  tem- 
perature, and  henre  there  is  danger  in  the  use  of  porcelain  vessels. 

Galtier,'  and  later  Catieac  and  Malet,'  have  exposed  the  tuber- 
culoas  expectoration  to  repeated  freezing  and  thawing,  and  a  tem- 
perature of  — 8°  C.  did  not  destroy  the  virulence  of  these  tuber- 
culous products. 

For  factory  and  workshop  use,  Piedoehl's^  enameled  iron  spit- 
toon, of  which  I  also  give  a  drav/ing  (Fig.  6),  seems  to  answer  all 
practical  purposes,  especially  if  its  cover  can  be  made  to  close  more 
tightly,  .so  that  flies  cannot  enter.  This  is  a  rather  important  item 
in  the  prophyla;;:3  of  tuberculosis.  Spillmann  and  Haushalter,^  of 
Nancy,  have  demonstrated  by  extensive  experiments  that  the  fly  may 
become  the  propagator  of  tuberculosis.  The  abdominal  cavities 
of  flies  caught  m  the  rooms  of  consumptives  were  found  to  contain 
the  liviuLj  bacilli,  so  also  did  the  fly-specks  scraped  from  the  walls 
and  windows  of  hospital  wards  and  rooms  where  consumptives 
habitually  sojourned.  The  same  experiments  were  repeated  and 
verified  by  Hofifmann  '.  Now,  the  danger  from  these  infected  insects 
is  twofold.  They  die  and  crumble  to  dust  which  contains  the  bacilli, 
and  the  micro-organisms  may  thus  enter  the  system  through  the 
respiratory  tract.  Or  the  fly  which  may  have  partaken  of  the 
tuberculous  expectoiation  deposits  its  excrements  at  the  next 
opportunity  upon  some  article  of  food,  whence  the  bacilli  con- 
tained in  the  deposit  find  their  way  into  the  alimentary  tract  of  man 
or  beast. 

Predoehl's  cuspidor — which  is  about  nine  i' ches  high,  eight 
inches  at  its  largest,  and  three  inches  ?t  its  smallest  diameter — 
can  be  suspended  at  any  height,  and  can  be  very  easily  cleaned 
and  disinfected. 

A  third  kind  of  spittoon  is  the  small  mug,  wliich  should  also  be 
of  some  unbreakable  material, — enameled  iron,  tin,  or  aluminum, — 
and,  of  course,  with  a  tightly  closing  cover.     On  account  of  its 


1  Galtier,  Congrts  |X)ur  111  tuberculose  a  Paris,  1 8.S8. 

''Straus,  "  Lit  'i'uberculose  et  son  I5,icille,"  I'aris,  1S95. 

3  Predoclil,  "  Der  Spucknapf,"  "  Miiiicliciier  med.  VVocliensclir. ,"  Oct.  22,  1895. 

*  Spillmann    et    IlL.iislialter,   "  I  )issiimiiiiition    ilu    liacilie  dc   la   t'.iberculosc  par  les 
inouclies,"  '•  C.  R.  de  I'Acadeniie  dt'i  Sciences,"  iS86,  vol.  iv,  p.  352. 

'  E.  HofTin.-tnn,"  Ueber  die  Verbreilung  der  'I'uherkulose  Uurch  unsere  .Stjbenfliegen," 
1888. 


COMMUNICABILITY    OF    PULMONARY    TUBERCULOSIS. 


41 


lightness,  I  prefer  the  last-mentioned  metal.  I  give  here  a  design 
of  the  form  which  seems  to  me  most  convenient  (Fig.  7). 
Another  k-ind  of  spittoon  of  practical  use,  at  home  or  in  institu- 
tions, is  the  Seabury  and  Johnson  spitting-cup,  made  of  imperme- 
able pasteboard,  to  fit  in  a  metallic  frame  with  handle  and  cover. 


I 


I'U,.    6.  — Br.     I'KKDOKHI.'S    Sl'ITTDON 

KOR  Factories  and  Workshops. 


\-u. 


-Si'IT-Cl  I'    FOR  I'SI:  ON  THK    \liKANT)A 
AND   AT   THK    BP.DSIDH. 


ould  also  be 
iluminum, — 
count  of  its 


let.  22,  1895. 
tierculose  par  les 

re  Stjbenfliegen," 


a. 
Fig.  S. 


Skakiky  AM)  Johnson's  Sim  itini;-iii'. 
a.  I-'ranie.    d.  l*\>l(ie(l  cardboaril. 


When  the  cup  is  filled,  the  pasteboard  is  taken  out  and  burned,  with 
its  contents.  These  are  the  cuspidors  for  patients  in  bed  or  for 
such  who  are  taking  the  rest  cure  on  the  veranda.  Patients  who 
arc  too  weak  tc  Miake  use  of  this  cup  should  have  at  their  bedside 
a  number  of  moist  rags,  which  should  be  burned  immediately  after 
use  or,  at  least,  before  tiiey  have  had  time  to  dry. 


m 
m\ 


I! 


I 


:   I: 


I 


r 


I! 


42 


PULMONARY   TUBERCULOSIS. 


Precnutioii 
against 
reiiifL'ction 
and  the 
expu'sioM 
of  p  irticlcs 
(if  spultmi. 


We  now  come  to  the  fourth  kind  of  spittoons — the  pocket  flask, 
which,  to  my  mind,  when  properly  and  faithfully  used  by  the 
pulmonary  invalid,  will  prove  one  of  the  most  important  factors  in 
the  prevention  of  tuberculosis.  It  should  be  carried  by  the  tuber- 
culous individual  all  the  time,  and  used  whenever  he  can  not 
conveniently  get  at  the  stationary  cuspidors.  One  of  the  most 
ingenious  pocket  spittoons  invented  is  Dr.  Dettweiler's  "  Husten- 
flaschchen,"  of  which  I  will  also  give  an  illustration  (Fig.  10). 
It  is  a  flask  of  blue  glass,  about  four  inches  long  and  six  inches 
in  its  largest  circumference,  provided  with  a  hermetically  closing 

top  and  bottom,  and  so  constructed  that  it 
can  easily  be  cleaned.  The  lid  flies  open  at 
a  slight  pressure  on  the  spring,  and  after 
use  is  closed  by  pushing  the  top  down  again. 
This  otherwise  excellent  flask  has  a  few  dis- 
advantages, which  I  have  sought  to  over- 
come by  the  construction  of  an  aluminum 
pocket  flask.  This  is,  of  course,  unbreak- 
able, which  can  not  be  said  of  a  glass  flask, 
where  the  danger  of  inoculation  in  case  it 
should  break  in  the  pocket  must  not  be 
forgotten.  As  can  be  seen  from  the  drawing 
(Fig.  11),  it  is,  like  Dettweiler's,  constructed 
so  that  its  contents  cannot  be  spilled  by  tip- 
ping over;  but  instead  of  being  of  three  pieces 
it  is  of  but  two,  can  easily  be  cleaned,  and 
boiling  will  not  injure  it.  Instead  of  six 
ounces  (which  is  the  weight  of  the  glass 
flask)  it  weighs  but  two  ounces.  Its  length 
is  four  inches  and  its  nearly  uniform  diameter  is  but  1^4  inches. 
Thus  the  aluniinum  flask  is  less  bulky,  can  be  manipulated  with 
more  ease,  and  will  attract  less  attention.  It  can  be  easily  hidden 
in  the  folds  of  a  handkerchief  when  used.  This  is  an  important 
point,  for  consumptives  are  nauirally  sensitive,  and  are  ever 
anxious  not  to  attract  attention  to  their  infirnn'ty. 

Tliere  is  one  precaution  to  be  observed  in  connection  with  the 
use  of  the  pocket  flask  and  the  cuspidor  in  general.  I  always  tell 
my  tuberculous  patients  never  to  use  the  same  handkerchief  for 
wiping  the  nose  that  they  use  to  wipe  their  mouths  after  having 
expectorated.     They  should  have  two  handkerchiefs  with  them, 


Fig.  10.— Or.  DKrrup.ii.KRs 

"  III  STKNIM.ASCIICIIHN." 


COMMUNICABILITY    OF    PULMONARY    TUBERCULOSIS. 


43 


and  always  hold  one  before  their  mouth  during  an  attack  of  cough- 
ing or  sneezing,  to  guard  against  the  expulsion  of  small  particles 
of  sputum.  Fliigge  and  Latschenko  '  have  demonstr^s^ed  the  need 
of  such  precaution  through  careful  and  extensive  experiments. 
They  requested  some  consumptives  to  cough  (but  not  to  expec- 
•■-^late)  in  a  large  glass  box.  The  patients  had  to  put  on  new 
I  •-  -^"T  coats  and  rubber  shoes,  to  make  the  detaching  of  particles 
jt  dried  sputum,  which  might  have  been  on  their  clothes,  impos- 
sible. Sterilized  glass  plates,  somewhat  moistened,  had  been  pre- 
viously placed  in  the  upper  portion  of  the  big  box.  Animals 
inoculated  with  the  substance  scraped  off  these  plates  were  ren- 
dered tuberculous. 


1 


II.  CloHet!.  *•    I'akoii  apart  for  cleaiiiiij;. 

Fig.  II.— Ur.  Knopi-'s  Tockkt  Sputim  I'i.ask. 


In  special  institutions — sanatoria  and  hospitals — one  can,  of 
course,  carry  out  prophylactic  measures  to  guard  against  the  expul- 
sion ■  t"  particles  of  sputum  which  wouUl  be  much  less  practicable 
for  /-V  uts  outside  of  such  establishments.  Professor  R.  Fraenkel, 
for  ex-iuple,  has  inaugurated,  at  the  Berlin  "  Charite,"  this  innova- 
tion :  All  the  tuberculous  inmates  must  wear  masks  (Fig.  12)  to 
catch  the  germs  they  expel  in  speaking  and  coughing  when  they 
are  in  the  common  room,  and  only  remove  them  while  eating  or 
expectorating.-      The    patients    soon    become  accustomed  to    the 


'  Flllgge,  "  Oeutsclie  med.  V/ochensclirift,"  1897,  No.  42. 

-I!.    Fraenkel,  " /.ur   I'rophylaxii' der  1  uherkulose,"   "  Iterl.   kliii.  Woclienschrifl," 
l8<)9.  No.  2.  • 


-J 

'-if 

Jlfc  1' 


CleaniiiB 
and  disin- 
fecting: 
cuspidors. 


44 


PULMONARY   TUBERCULOSIS. 


Ot  ■< — 


mask,  as  by  impregnating  the  gauze,  which  is  held  in  place  by  the 
metallic  frame,  with  some  medicinal  substance  they  suppose  it  is 
to  be  worn  for  theii  iv  nersonal  benefit,  instead  of  for  the  pro- 
tection of  others.  Bar  •  •'  frequently  found  on  the  gauze.  It 
is,  of  course,  .self-understo.  that  the  gauze,  lint,  or  cotton  removed 
from  these  respiratory  masks  should  be  burned  immediately,  and 
the  masks  disinfected  at  regular  intervals. 

A  patient  should,  if  possible,  have  two  pocket  flasks,  .so  as  never 
to  be  without  while  one  is  being  cleaned.  In  hospitals  and  sanatoria 
the  same  rule  should  hold  good  for  the  fixed  cuspidors.  In  such 
institutions  the  person  who  attends  to  the  cleaning  ofthe.se  vessels 
should,  during  his  work,  be  provided  with  rubber  gloves,  so  as  to 

remove  all  possible  danger 
of  inoculation  through  an 
abrasion  of  which  he  might 
not  be  aware. 

The  most  thorough  meth- 
od of  cleaning  any  cuspidor 
filled  with  tuberculous  spu- 
tum is  certainly  the  one  re- 
commended by  Professor 
Grancher,  of  Paris,'  consist- 
ing in  placing  the  spittoons — 
contents  and  all — in  boiling 
water,  where  they  are  left  for 
five  or  ten  minutes;  by  the 
addition  of  some  bicarbonate  of  soda  the  boiling-point  will  be 
raised  to  102°  or  103°  C,  which  will  destroy  the  tubercle  bacilli 
most  certainly.  The  next  best,  and  perhaps  the  most  convenient 
method,  is  to  mix  the  tuberculous  e.xpectoration  freely  with  a  five 
per  cent,  solution  of  carbolic  acid.  After  this  in  order  of  efficacy 
comes  the  bichloride  solution  of  i  to  lOOO.  This  should  always 
be  u.sed  in  combination  with  tartaric  acid,  citric  acid,  or  some  other 
preparation  that  will  prevent  the  coagulation  of  albumen.  The 
strength  of  the  solution  of  corrosive  sublimate  should  be  i  to  500. 
According  to  the  experiments  of  Yersin,*  it  took  thirty  seconds  to 


\-\i..  12.— I'Roi-.  FKAKNKia.'s  Moriii  Mask. 

(!4  n.'lural  size.) 

a.  Metal  ling.    b.  Supporter,    c.  Saddle,     d.  lilastic 

band.    e.  KiuHS  for  fasienliiK. 


'  Granclier,  "Maladies  de  I'appareil  respiratoire,"  I'aris,  1X90. 

'■  Yersin,  "  De  raction  de  ciui'iciiies  niiliseptique.s  et  de  la  cliaieur  sur  le  liacille  do  la 
tubercirlose,"  ".\niiales  de  I'lnstiliit  I'astevir,"  1888,  p,  60. 


'Hi 


COMMUNICABILITY   OF    PULMONARY   TUBERCULOSIS. 


45 


kill  the  tuberculous  germs  immersed  in  a  five  per  cent,  solution  of 
carbolic  acid,  while  it  took  ten  minutes  before  all  the  germs  were 
killed  when  immersed  in  a  bichloride  solution  of  i  to  looo.  Every 
stationary  cuspidor,  and  also  the  hand-cup  in  the  sick-room  or  on 
the  little  table  next  to  the  steamer-chair  where  the  patient  takes 
his  rest  cure,  should  be  filled  every  morning  to  about  one-fifth 
with  a  five  per  cent,  carbolic  acid  solution.  Of  late,  wood  vinegar 
(acidum  pyrolignosum)  has  proved  to  be  an  excellent  disinfectant 
for  tuberculous  secretions.  It  kills  the  bacilli  after  six  hours,  and 
lakes  also  from  the  expectorated  matter  its  unpleasant  aspect.^ 

To  encourage  the  use  of  the  pocket  flask,  one  must  make  its 
manipulation,  and  especially  the  process  of  cleaning,  as  simple  as 
possible.  Thus  the  directions  which  accompany  the  aluminum 
pocket  flask  above  referred  to  are  as  follows  :  To  empty  the  flask, 
unscrew  the  top  and  pour  the  contents  into  the  water-closet ;  or 
fold  a  newspaper  into  several  layers,  pour  the  contents  on  to  this, 
and  throw  the  whole  at  once  into  the  fire,  being  careful  not  to  spill 
any.-  Rinse  the  flask  in  hot  water  and  wash  the  hands  imme- 
diately afterward. 

Some  consumptive  individuals  will  not  use  the  pocket  flask,  in 
spite  of  all  persuasion,  for  the  simple  reason  that  they  do  not  wish 
to  attract  attention  to  their  malady.  For  these  there  is  but  one 
thing  to  do — to  tell  them  to  use  squares  of  cheap  linen  handker- 
chiefs, or  Japanese  paper  handkerchiefs  specially  manufactured  for 
that  purpose,'^  which  can  be  burned  after  use.  But  I  should  insist 
that  they  place  in  their  pockets  a  removable  lining  of  rubber  or 
other  impermeable  substance  which  can  be  thoroughly  cleaned. 
This  additional  pocket  could  be  fastened  to  the  inside  of  the  ordi- 
nary pocket  by  clamps,  and  thus  be  of  no  inconvenience  to  the 
patient.  Of  course,  all  invalids  using  handkerchiefs  as  receptacles 
for  expectorations  take  their  chances  of  infecting  their  hands,  and 
should  be  enjoined  never  to  touch  any  food  without  having  thor- 
oughly washed  them. 


1 15: 


m 


f  il 


'  "  Zeitschrift  filr  Krankenpflege,"  .\x,  No.  ')•  ' 

^  For  the  prailiial  suggestion  of  using  newspa[ier  for  tliis  purpose  I  am  indebted  to 
I'rof.  Piudden,  of  Columbia  I'niversity. 

'  Weise,  "  Ilnndixercbiefs  for  Consumptives,"  "  Lancet,"  Nov.  14,  l8yl. 


r  le  bacille  de  la 


I      1 

1 

il 

> 

'i     1 
,1     1 

;  1 

il 

46 


PULMONARY   TUBERCULOSIS. 


INFECTION   BY   INGESTION, 

The  saliva  of  consiimptives  frequently  contains  the  tubercle 
bacilli.  Petit,'  Freudenthal,"  and  many  others  have  reported  their 
clinical  experience  in  this  respect,  which  shows  that  there  is  real 
danger  in  kissing  tuberculous  patients  on  the  mouth.  The  napkins 
used  by  consumptives  should  be  boiled  after  each  meal.  If,  for 
economic  reasons,  a  freshly  washed  napkin  can  not  always  be  had, 
Japanese  paper  napkins,  which  are  burned  after  use,  may  be  sub- 
stituted. Knives,  forks,  spoons,  glasses,  etc.,  should  be  thoroughly 
boiled  or  rterilized  after  each  use.  How  important  it  is  to  tell  the 
patient  about  all  these  things,  and  explain  to  him  the  reasons,  may 
best  be  illustrated  by  the  following  anecdote :  I  was  called  in  con- 
sultation to  see  a  phthisical  lady,  and  on  the  way  there  the  family 
physician  told  me  how  particular  he  had  been  to  warn  his  patient 
of  the  contagious  nature  of  her  disease.  On  our  arrival  we  found 
the  young  mother  with  a  baby  a  few  months  old  in  her  arms.  She 
was  preparing  the  food  for  her  infant,  which  sacred  duty  she  would 
intrust  to  no  one  else.  She  had  one  .spoon  for  herself  and  baby, 
with  which  she  tasted  the  food  to  judge  of  its  palatability  and  tem- 
perature. She  then  told  me  that  since  the  good  doctor  had  told 
her  that  her  disease  was  contagious  she  had  never  once  kissed  her 
darling  child.  To  the  mind  of  this  unfortunate  mother  it  was  the 
kiss  alone,  the  direct  contact,  that  was  capable  of  transmitting  the 
disease,  and  she  restrained  herself  from  caressing  her  child.  But, 
unconsciously,  she  was  conveying  the  bacillus  into  the  very  food  of 
her  infant. 

Consumptive  men  should  either  wear  no  beard  at  all  or  keep 
their  mustaches  and  beards  closely  cut,  so  that  they  may  be  easily 
kept  clean  and  not  become  the  cause  of  infection  or  reinfection. 

It  is  of  great  importance  to  tell  the  patients  never,  out  of  false 
modesty  or  for  any  other  reason,  to  swallow  their  expectoration. 
There  is  always  danger  of  an  intestinal  infection.  Among  the  in- 
sane tuberculous  patients,  secondary  intestinal  tuberculosis  is  ot 
most  frequent  occurrence.'     There  seems  to  reside  a  certain  danger 


'  L.  H.  Petit,  "  Sur  quelques  modes  pen  connus  de  contngion  de  la  tuberculose  par 
la  voie  IniLcale,"  "  Keviie  <le  la  Tuberc,"  I,  ir,  1894. 

^  Freudenthal,  "  Kleinere  lieitrane  ziir  .'\ctiologio  der  I.ungeiUuDeri- iilose,"  "  .Vrcliiv 
fill-  Laryiigolonie,"  Hd.  v. 

^  Mosler,  "  L'eher  die  Inft'ction  der  DariiiBclilelmliaul  beini  Versclihickeii  tuberkulijser 
Sputa,"  "Deutsclie  tiifd.  \.  ocliensclirid,"  lS8j,  No.  19. 


COMMUNICABILITY   OF   PULMONAKY   TUBERCULOSIS. 


47 


in  the  cigars  and  cigarettes  that  are  made  by  hand.     The  saUva  Bacilli  in 
which  the  tuberculous  laborer  uses  to  fasten  the  cover  of  the  cigar '^"*"'*' 
or  cigarette  may  convey  the  tubercle  bacillus  to  the  smoker.     Dr. 
J.  C.  Spencer,  of  the  San  Francisco  Board  of  Health,  has  actually 
demonstrated  the  presence  of  these  bacilli  in  various  specimens  of 
cigars  submitted  to  him  for  examination.     Now,  although  the  nico- 
tine may  kill  the  bacillus,  it  does  not  render  it  thereby  inoffen- 
sive.    Prudden  and  Hodenpyl '  showed  by  their  very  interesting 
experiments  that  the  dead  tubercle  bacilli  still  contain  a  specific 
protein  capable  of  doing  harm  in  the  living  tissue.     Grancher  and 
Ledoux-Lebard,"  who  carried  on  similar  experiments,  called  the 
cellular  reaction   produced  by  the  dead  bacillus  "  necro-tubercu-Nccro- 
losis."     In  view  of  the  possible  danger  of  this  mode  of  infection, cuiosis. 
it  would,  of  course,  be  well  to  advise  all  persons  predisposed  to 
consumption  not  to  smoke  at  all,  and  the  same  rule  may  hold  good 
for  all  individuals  whose  constitution  is  weakened  from  some  cause 
or  other. 

Infection  from  the  ingestion  of  tubercle  bacilli  is  also  made  pos- 
sible by  the  patient  soiling  his  hands  with  the  expectoration 
directly  or,  as  has  been  stated  above,  through  the  medium  of  a 
soiled  handkerchief,  and  then  touching  his  food,  thus  conveying  the 
bacilli  to  the  digestive  tract.  That  such  infection  from  the  hands 
in  pulmonary  phthisis  is  possible  has  been  very  ably  demonstrated 
by  Dr.  E.  R.  Baldwin,  of  Saranac  Lake,  in  an  article  which  appeared 
in  the  "  Philadelphia  Medical  Journal"  of  December  3,  1898. 

A  tuberculous  patient  should  always  sleep  alone,  and  in  a  bed 
which  should  be  freely  aired  during  the  day-time.  Very  weak- 
patients  who  do  net  leave  the  bed  should,  whenever  it  is  possible, 
have  a  second  bed  placed  in  their  room,  so  as  to  be  able  to  change. 
It  is,  of  course, -always  desirable  that  a  consumptive  should  not  or  room, 
sliarc  his  room  with  any  one  else.  1  he  attendant  or  nurse  should  etc. 
sleep  in  an  adjoining  room.  The  soiled  linen  of  consumptive 
patients  should  be  placed  in  water  immediately  after  the  removal 
from  bed  or  body,  and  be  washed  separately,  or  at  least  boiled 
before  it  is  given  to  the  general  laundry. 


.'  «i 


'  I'ruddeii  ami   IloiUiipyl,  "  Studies  (iii  the  Action  of  IJcad  Uacleiia  in  the  Living 
llody,"  "  N.  Y.  Med.  Journal,''  June  (),  20,  1S93. 

-  (iranclier  ct  l.edouxLebard,   "  'I'uljcrculosc  aviairc  et  liuniaine,"   "  Arch,  de  nicd, 
ixpiriin.  etd'anatoin.  pathol.,"  1892,  p.  25. 


mi 

m 


hi' 


48 


PULMONARY   TUUERCULOSIS. 


Ill 

1 


'i 


n 


] 


Holy  water 
and  com- 
mutiioti- 
cups. 


Bible- 
kissing. 


Ingestion 
of  tubercu- 
lous food. 


The  room  of  a  tuberculous  patient  should  be  sunny,  cheerful, 
and  well  ventilated.  The  floor  should  be  covered  by  small  rugs 
only.  Velvet  or  plush-covered  furniture  should  be  replaced  by 
such  as  will  not  accumulate  dust.  Raising  dust  by  sweeping  with 
a  broom  should  never  be  allowed  in  any  sick-room,  but  particu- 
larly not  in  one  occupied  by  a  pulmonary  invalid.  A  moist  mop 
should  be  used  to  remove  the  dust  from  the  floor,  and  the  furniture 
should  be  wiped  carefully.  In  case  of  death  or  removal,  the  room 
that  has  been  occupied  by  a  consumptive  should  be  thoroughly 
disinfected  by  placing  therein  a  good  formaldehyde  generator  for 
twenty-four  to  thirty-six  hours ;  then  carefully  cleaned,  scrubbed, 
whitewashed,  papered,  or  painted  before  being  occupied  again. 
The  carpet,  rugs,  bedding,  etc.,  should,  of  course,  be  disinfected 
with  the  room. 

Just  as  it  must  be  considered  unhygienic  and  a  probable  cause 
of  the  propagation  of  diseases,  such  as  diphtheria,  influenza, 
tuberculosis,  etc.,  to  besprinkle  one's  self  with  holy  water  which  has 
been  standing  for  days  in  churches,  and  in  which  the  multitudes 
have  dipped  their  fingers,  so  does  it  seem  unwise  to  use  a  common 
communion-cup  in  the  Protestant  churches.  The  individual  com- 
munion-cup is  certainly  to  be  preferred.  The  Indiana  State  Board 
of  Health  has  taken  up  this  matter  recently,  and  recommended  the 
use  of  individual  cups. 

On  the  same  principle  we  should  also  condemn  the  custom  still 
frequent  in  this  country  of  kissing  the  Bible  when  being  sworn 
before  court.  It  is  gratifying  to  note  here  that  Governor  Roose- 
velt, of  the  State  of  New  York,  has  signed  a  bill  to  permit  wit- 
nesses to  dispense  with  kissing  the  Bible  in  the  administration  of 
oaths.  Magistrate  Kudlich,  of  the  Harlem  Court,  in  commenting 
upon  this  health-measure,  said  that  at  one  time  he  had  noticed  a 
witness,  whose  lips  were  a  mass  of  ulcerated  patches,  kiss  the 
Bible  when  being  sworn.  The  Magistrate  had  at  once  ordered  the 
book  to  be  destroyed,  and  had  given  notice  that  thereafter  no  wit- 
nesses should  be  asked  to  kiss  the  book. 

The  most  frequent  cause  of  infection  by  ingestion  is  due  to  the 
use  of  tuberculous  milk  or  meat  as  nutriment.  In  our  chapter 
on  bovine  tuberculosis  I  will  endeavor  to  explain  at  length  why 
the  contraction  of  tuberculosis  by  ingestion  is  still  so  very  fre- 
quent, and  more  frequent  than  physicians  and  sanitaria"  are 
usually  willing  to  admit.     Here  I  will  only  say  that  in  c.iudren 


COMMUNICABILITY    OF    PULMONARY    TUUEKCULOSIS. 


49 


it  is  the  delicate  intestinal  epithelium  which  offers  to  the  bacilli 
contained  in  tuberculous  milk  the  most  favorable  abiding-place. 
And  the  reason  we  so  rarely  find  primary  tuberculosis  in  adults,  in 
spite  of  the  frequent  injjestion  of  tuberculous  substances,  is  to  be 
explained  by  the  fact  that  with  them  the  epithelial  lining  of  the 
intestines  is  stronger  and  resists  the  colonization  of  cultures.  If 
the  individual  is  in  poor  health,  and  the  phagocytic  power  of  the 
blood  enfeebled,  the  bacilli  ingested  by  a  grown  person  usually 
find  the  apices  of  the  lungs  to  be  the  locus  minoris  rcsistcntice,  which 
they  reach  through  the  medium  of  the  circulation  of  the  blood. 

The  individual  can  only  protect  himself  against  the  ingestion  of 
tuberculous  substances  by  boiling  or  .sterilizing  all  milk  and  thor- 
oughly cooking  all  meat  of  doubtful  origin. 

Midwives  and  also  physicians  will  often,  in  the  presence  of  anD.ingtrof 

asphyxiated  newborn  child,  apply  their  mouth  to  that  of  the  infant  inomh  res- 
piration in 
and  inflate  the  child's  chest  in  order  to  bring  its  respiratory  organs  iispiiy^i- 

°  '■  .  .         nted  iti- 

into  play.  If  the  operator  is  consumptive,  the  danger  of  imparting  f^"'"*- 
his  or  her  disease  to  the  infant  is  evident.  To  avoid  such  possi- 
bility the  mouth-to-mouth  respiration  should  be  replaced  by  the 
safer  method  of  using  the  catheter,  as  recommended  by  Tar- 
nier  and  Lusk.  Laborde's  method  of  rhythmical  traction  of  the 
tongue  will  also  often  suffice  to  cause  the  child  to  breathe.  The 
habit  some  midwives  have,  of  sucking  the  mucus  from  the  child's 
throat  by  direct  application  of  the  mouth,  is  equally  to  be  con- 
demned. Reich  reported,  in  the  "  Berliner  med.  VVochenschrift," 
No.  37,  187.S,  ten  cases  of  tuberculous  infection  through  this 
method.  A  midwife  in  the  village  of  Neuenberg  became  consump- 
tive in  1874,  and  died  of  this  disease  in  July,  1876.  Ten  children, 
without  hereditary  predisposition,  attended  by  this  midwife  between 
April,  1875,  and  May,  1876,  died  before  reaching  the  age  of  seven- 
teen months.  This  consumptive  midwife  was  in  the  habit  of  suck- 
ing the  mucus  from  the  mouths  of  newborn  children,  and  blowing 
air  into  their  mouths  when  there  was  the  slightest  sign  of  asphyxia. 

The  physician  who  is  attendin<r  a  consumptive  eneagfed  in  such  Trades  rc- 
occupation   as  that  of  a  dairyman,    a   milk-dealer,  baker,  confec- special 

'  '  _         supervis- 

tioner,  cook,  or  butcher,  should  be  particularly  careful  in  instructing 'o''- 
his  patient  concerning  the  danger  to  himself  and  others  of  his  being 
careless  with  his  expectoration  or  other  secretions.     If  the  patient 


I 


f    W 


1   f  If 

I 


•I 


I'l''!. 


See  also  chapter  on  l)ovine  tuberculosis,  page  66. 


ffl 


50 


PULMONAKY   TUBEKCULOSIS. 


p 
■f   ;n 


Precaiilioii 
to  lie  taken 
in  bakeries. 


Danger 
from  cares- 
sing domes- 
tic pets. 


is  refractory,  the  phys'cian's  duty  would  be  to  report  him  to  the 
authorities  as  a  menace  to  public  health. 

A  very  recommendable  precaution  was  recently  instituted  in 
some  of  the  large  bakeries  of  Germany,  in  connection  with  the 
handling  and  transporting  of  bread.  The  moment  the  bread  comes 
out  of  the  oven,  while  it  is  still  too  hot  to  be  handled,  it  is  placed, 
by  the  aid  of  a  shovel,  upon  a  piece  of  wrapping-paper  large  enough 
to  envelop  the  whole  loaf  liy  twisting  the  two  ends  of  the  wrap- 
per the  bread  is  completely  inclosed.  This  is  certainly  a  more 
hygienic  way  than  the  one  now  in  vogue  in  nearly  all  countries. 
A  loaf  of  bread  coming  from  one  of  the  public  bakeries,  and 
especially  in  the  di.stricts  of  the  poor,  usually  passes  through  any 
number  of  hands.  Sometimes  it  may  be  handled  by  those  afflicted 
with  disease,  and  it  often  pas.ses  through  hands  of  doubtful  cleanli- 
ness before  it  reaches  the  consumer's  mouth.  No  one  would  think 
of  washing  the  crust  of  bread  which  has  been  e.\po.sed  to  all  sorts 
of  contaminating  influences  in  the  bakeshop,  bakery-wagon,  gro- 
cery-store, etc.;  but  we  would  not  think  of  eating  any  other  article 
of  food  treated  in  the  same  way  without  submitting  it  to  a 
thorough  cleansing.  I  believe  it  would  be  a  veritable  protection 
to  the  people  if  the  sanitary  authorities  would  compel  all  public 
bakers  and  bread-dealers  to  institute  some  such  sanitary  method 
of  handling  the  bread  as  I  have  described. 

In  speaking,  on  page  46,  of  the  danger  from  the  .sputum  and 
saliva  of  tuberculous  patients,  we  have  already  referred  to  the  un- 
sanitary habit  of  kissing.  Many  a  time  consumption  has  been 
transmitted  in  this  way  from  one  member  of  a  family  to  another, 
but  I  desire  yet  to  call  attention  to  the  equally  dangerous  habit  of 
kissing  domestic  pet  animals.  The  parrot  and  the  canary-bird  are, 
perhaps,  the  animals  which,  when  domesticatec'.  ^ake  tuberculosis 
most  easily,  and  then  constitute  a  real  danger  in  the  household.' 
Dogs  and  cats  come  next  in  order  of  frequency  of  tuberculous  in- 
fection. Kissing  and  caressing  all  such  domestic  pets,  especially 
by  children,  should  be  strictly  forbidden.  The  authoritie  •  should 
have  a  right  to  destroy  small  domestic  animals  if  they  are  afflicted 
with  tuberculosis. 

In  case  of  intestinal  tuberculosis  it  is,  of  course,  essential  to  dis- 

'  .Straus,  I..  "  Sur  l.i  tiil)erciil().se  dii  partxiuet."  "Arch,  de  mod.  experim.," 
Jaiuiary,  1896.  Wi-ise,  T.,  "  Consiiin|)tii)ti  and  Canaries  "  (The  I  lospilnl).  "Journal 
of  tlie  American  Med.  Assoc,"  vol.  xxxii. 


M 


COMMUNICAlllLITV    OF    PULMONAKV    TUllKKCULOSIS. 


51 


infect  tlie  stools  by  eitlier  a  five-per-cent.  carbolic-acid  solution  or 
a  corrosive-sublimate  solution  of  I  to  1000,  or  by  reducinj^  tlicin 
to  ashes  in  an  oven  constructed  for  the  purpose.  The  burying  of 
either  the  expectorated  or  fecal  matter  from  the  tuberculous 
patient  without  its  being  previously  treated  by  one  of  the  above 
methods  is  not  safe.  Lortet  and  Despeignes  reported  to  the  Paris 
Academy  of  Science,  on  January  25  and  July  4,  IiSqz,  their  ex- 
periments with  the  earth-worm,  which  show  that  this  lumbricus 
may  be  instrumental  in  bringing  to  the  surface  again  the  bacilli 
from  buried  tuberculous  substances.  Animals  which  might  chance 
to  pasture  in  the  vicinity  of  spots  where  such  substances  have  been 
buried  are  certainly  in  great  danger  of  ingesting  the  tubercle  bacilli. 
All  persons  handling  vessels  containing  tuberculous  substances 
should  be  very  careful,  for,  while  not  having  the  disease  themselves, 
they  may  unconsciously  transmit  it  to  others. 


I'ossihle 
tr:iiisniis- 
sioii  of  tii- 
beri  iilosis 
l>y  rarlli- 
woiins. 


INFECTION  I^Y  INOCULATION. 

Consumptives  who  attend  to  the  cleaning  of  their  spittoons 
themselves  must  be  especially  prudent.  If  they  have  anywhere  a 
cutaneous  abrasion,  they  must  be  careful  not  to  soil  it  with  saliva 
or  expectoration.  The  habit  of  putting  an  injured  finger  in  the 
mouth  has  not  infrequently  caused  local  tuberculosis  in  consump- 
tives, the  result  of  an  auto-inoculation.'  Surgeons  and  nurses 
should  be  particularly  careful  when  attending  surgical  cases  of 
tuberculosis.  I  have  had  occasion  to  observe  such  an  inoculation 
in  the  service  of  a  colleague  of  mine.  The  unfortunate  nurse 
came  well-nigh  losing  his  whole  hand  from  dressing  a  tuberculous 
wound.  The  seat  of  entrance  of  the  tuberculous  infection  was  only 
a  slight  abrasion  of  the  skin  which  had  passed  unobserved. 

Pathologists  handling  fresh  tuberculous  specimens,  physicians 
performing  autopsies,  and  students  dissecting  tuberculous  subjects, 
are  also  greatly  exposed  to  the  danger  of  becoming  inoculated  with 
tuberculosis.  The  "  piquure  anatomique  "  has,  alas!  too  often 
develop'^'d  iiiLo  a  serious  tuberculous  infection.  To  incise  freely 
with  an  aseptic  instrument  at  the  seat  of  inoculation  and  apply 
a  careful  dressing  of  bichloride  of  i  to  3000  seems  the  best  imme- 
ake  in  case  such  accident 


5tep 


IPP 


'  K.  Ullinaiin,  "  Cutaneous  Tulierculosis  by  Auto-infection,"  "  New  York  L.incet," 
A]iril,  1S9S. 


'M:' 


!'i 


52 


PUI-MONAKY   TUIIKKCULOMS. 


1     .     -Hi 


t  if- 


Infection 
from  wc't- 
iiurse  to 
child,  anil 
vice  versa, 


Vaccina- 
tion. 


Infection 
tlirougli 
sexual  rela 

tiOMS. 


Infection  frdin  wet-nurse  to  child,  and  vice  versa,  is  possible. 
Happily  the  cases  where  a  tuberculous  mother  nurses  a  child  are 
now  exceedingly  rare ;  thus  one  sees  this  mode  of  inoculation 
seldoni,  but  against  the  other  we  should  always  be  on  guard. 

1  would  have  no  hesitation  to  give  the  child  of  a  consum])tive 
mother  to  a  healthy  wet-nurse,  provided  a  most  thorough  exami- 
nation of  the  infant  revealed  no  sign  or  sympton^i  of  tuberculous 
infection  ;  but,  if  tliere  is  the  sliglitcst  doubt,  a  wet-nurse  should 
not  be  exposed  to  the  probability  of  becoming  infected  by  the  child. 
Weber's  case,  cited  in  his  Croonian  lectures  of  1885,  gives  a  very 
striking  example  of  the  possibility  of  a  tuberculous  child  commu- 
nicating the  disease  to  a  healthy  wet-nurse  who  had  no  hereditary 
predisposition. 

The  possibility  of  transmitting  the  tuberculous  disease  to  a  child 
through  vaccination  can  not  be  denied,'  especially  when  one  con- 
siders that  the  vaccine  is  now  almo.st  exclusively  obtained  from 
young  bovine  animals.  Although  Villain's  statistics  show  a  com- 
parative rarity  of  tuberculosis  in  calves  between  the  ages  of  four 
to  six  months,  it  seems  to  me  good  practice  to  follow  Brouardel's 
suggestion  -  that,  in  order  to  obtain  absolute  security,  the  best 
thing  would  be  to  slaughter  the  animals  immediately  after  they 
have  served  as  vaccinifers,  to  keep  the  vaccine  obtained  and  not  to 
use  it  until  the  examination  of  the  slaughtered  animals  had  shown 
that  there  was  no  trace  of  tuberculosis  in  their  organs. 

That  a  tuberculous  infection  can  take  place  through  sexual  rela- 
tions has  been  again  and  again  demonstrated.  All  phthisio-thera- 
peutists  have  occasionally  met  with  such  cases.  I  only  need  to 
refer  to  the  works  of  Reclus,^  Schuchardt,'  Carrera,''  and  Petit." 
I'^ducation  in  private  by  the  family  physicians,  and  in  some  cases, 


1  Surmont,  II.,  Article  "  Vaccine,"  "  'I'raite  de  Midecine  et  de  Tlicrai)."    Hrouardel, 
Gilbert,  et  Girondc,  vol.  i,  1895,  p.  207. 

2  I$rouardel,  Article  "  Vaccina,"  "Twcnlicth  Century  Practice." 

3  Reclus,  P.,  "Clin.  chir.  do  I'HOtel  Dieu,"  Paris,  1888  (514-527). 

♦  Schuchanlt,  K.,  "  Die  UebertragungderTuberkulose  auf  dem  Wege  des  geschlecht- 
lichen  Verkehrs."     "Arch,  fiir  klin.  Medicin,"  lierlin,  1892,  xi.iv. 

°  Carrera  y  Miro,  "  Conlagio  tulierculosD  por  h.  via  genital."     ("  (jac.  nied.  catal.," 
Harcelona,  1888  XI,  p.  385). 

*  Petit,  L.  II.,  "  Tuberculosa  et  rap|X)rl.s  ak  ore"     "  Revue  de  la  Tuberculosa,"  vol. 
II,  p.  234. 


COMMUNICAHILITY    OF    PULMONAKV   TUHKRCULOSIS. 


53 


perhaps,  the  sanitary  '^olice  intervention,  can  only  do  the  necessary 
prophylactic  work. 

Of  less  frequent  causes  of  propagating  tuberculosis,  but  which, 
in  the  light  of  modern  sanitary  science,  can  and  should  be  pre- 
vented, I  will  cite  first  the  ritual  act  of  circumcision,  practised 
according  to  Jewish  rites.  This  operation  has,  in  numerous  in-";"^.{!",^ 
stances,  been  the  cause  of  transmitting  to  an  iimocent,  healthy f|J,,'','|,',[.'j"f' 
child  the  disease  in  question.  The  tuberculous  inoculation  mani-'""" 
fests  itself  first  as  a  local  disease  of  the  genital  organs,  from  whencf, 
in  a  great  number  of  cases,  it  becomes  generalized.  Of  the  earlier 
cases  reported,  I  will  mention  the  one  of  Lindemaiu.  :  "Two 
chiklren  who  were  circumci/ed  by  a  man  who  was  in  the  last  stage 
of  consumption,  and  who,  after  the  circumcision,  su-ked  the  pre- 
puce, according  to  the  Jewish  rites,  both  became  infected  with 
ulcers  on  the  prepuce  and  swelling  of  the  genital  glands.  One 
recovered;  the  other's  infection  continued,  the  child  developing 
Pott's  disease  and  dying  finally,  after  a  few  years'  suffering,  from 
pulmonary  phthisis." 

Since  then  the  surgical  literature  of  all  countries,  where  Israelites 
practise  this  rite,  occasionally  contains  notes  of  cases  of  tubercu- 
lous infection  through  this  modus  ■>t>cianiU.  Professor  A.  Jacobi, 
of  New  York,  had  the  courtesy  t«,  tell  me  that  he  remembers 
having  seen  as  many  as  tweWe  cast,  of  tuberculosis  following 
ritual  circumcision.  Drs.  Ware  and  ?»loschkowitz,  of  the  same  city, 
have  also  very  kindly  reported  to  me  several  recent  cases  of  the 
same  kind.  Dr.  Willi  Meyer,  in  a  very  able  paper,  read  before  the 
Scientific  Union  of  German  Physicians  of  New  York,  on  March 
25,  1887,-  reporting  one  of  his  own  observations  of  such  tuberculous 
infection,  calls  attention  to  the  manifold  dangers  to  which  a  child 
is  exposed  throuj^h  the  performance  of  this  rite,  and  comes,  with 
Professor  Maas,'  to  the  conclusion  that  it  should  be  the  duty  of 
every  physician  to  protest  against  ritual  circumcision.  It  is  well 
known  that  syphilis  and  diphtheria  have  also  been  transmitted 
through  this  suction  process,  and,  again,  that  through  lack  of  skill 


■■M 


'  I-iiKlemaiiii,  "  Deutsche  med.  Wochensclirift."  No.  30,  188,5. 

*  Meyer,  "  Kin  Fall  von  Impf-Tuberkulose  in  Folge  ritueller  Circumcision."  "  \.  V. 
Med.  Presse,"  Jiini,  1887. 

"  Maas,  Konig's  '•  I.elirbuch  der  spec.  Cliirurgie,"  4.  .Aull.,  11,  p.  588. 


^iii; 


M  \ 


54 


PULMONARY   TUBERCULOSIS. 


Mow  this 
rite  may  be 
l-'erformed 
with  c>.'Ri  • 
parative 
safety. 


Tattooing. 


in  after-treatment  .secondary  hemorrhage,  erysipelas,  and  gangrene ' 
have  ensued.  Too  uiany  a  young  life  has  thus  been  needlessly 
sacrificed.  The  operation  of  circumcision,  when  skilfully  and 
rapidly  performed,  is  in  itself  trifling,  but  the  sucking  of  the  prepuce 
afterward  makes  it  dangerous.  Since  it  will  be  difficult  to  stop 
this  practice  by  a  simple  protest  on  the  part  of  physicians,  and  as 
the  law  cannot  interfere  with  the  free  exercise  of  a  religious  rite,  I 
should  suggest  as  a  remedy  that  only  such  persons  should  be 
allowed  to  perform  circumcision  as  have  shown  the  necessary  skill 
before  a  medical  board  of  examiners,  and  that  every  time  they  are 
called  upon  to  perform  the  rite  they  should  submit  themselves  to 
a  medical  examination.  Only  when  bearing  a  certificate  from  a 
regular  physician,  stating  the  absolute  freedom  from  specific  dis- 
eases, should  they  be  allowed  to  perform  ritual  circumcision. 

As  another  reliable  prophylactic  measure  against  the  possibility 
of  inoculating  the  child,  when  the  parents  insist  upon  tiie  orthodox 
method  of  circumcision,  is  the  suction  by  the  aid  of  a  glass  tube, 
as  practised  in  France  and  Germany. 

I  will  also  mention  the  possibility  of  inoculating  tuber- 
culosis by  the  process  known  as  tattooing.  Messrs.  Collins  and 
Murray  reported  no  less  than  three  cases  in  the  "  British  Medical 
Journal  "  of  June  i,  1895.  They  were  three  boys  of  the  age  often, 
thirteen,  and  fifteen,  respectively,  all  inoculated  by  the  same  person, 
and  all  three  died  from  general  tuberculosis.  Not  to  allow  such 
useless  and  dangerous  practice  would  seem  the  only  prophylactic 
remedy. 


Before  closing  with  the  subject  of  the  communicability  of  pul- 
monary tuberculosis,  I  desire  to  return  to  the  recent  experiments 
of  Fliigge  and  his  pupils.-  While  by  no  means  disproving 
the  conclusions  of  Cornet  and  his  followers,  in  regard  to  the 
danger  of  dried  tuberculous  sputum  as  a  means  of  propagating  the 
disease,  these  experiments  have  nevertheless  added  a  good  deal  to 
our  knowledge  of  the  methods  of  tuberculous  infection.  We  have 
already  referred  to  Fliigge's  work  in  speaking  of  the  danger  which 


'  I'rotliers,  A.,    "Gangrene  of  the  I'enis  After  Ritiinl  Circumcisioii,"     "  Medical 
Record,"  Jan.  30,  1897, 

2  "  Zeitsclirifl  fiir  llyg.  iind  Infectionskrankh.,"  1899,  vol,  \xx,  No.  i. 


n 


COMMUNICABILITY   OF   PULMONARY   TUBERCULOSIS. 


55 


may  result  from  the  expulsion  of  particles  of  sputum  containing 
bacilli  during  the  act  of  coughing  or  sneezing,  and  have  recom- 
mended holding  a  handkerchief  before  the  mouth  and  nose  at  such 
moments,  and,  in  addition,  where  it  is  practical,  the  use  of  Fraen- 
kel's  mouth-mask. 

That  an  expulsion  of  particles  of  infectious  sputum  is  possible, p^^^j^j^ 
even  during  the  act  of  speaking,  must  also  be  admitted.     The  very  ^|,'|'|^J^p"'"' 
interesting  experiments  of  Latschenko  and  Heyniann  in  the  labora-'*'""''""*^" 
tory  of  Professor  Fliigge  have,  however,  demonstrated  that  for  the 
infection    to   take    place   through    the   expulsion  of  particles    of 
sputum  a  close  proximity  to  the  invalid  is  essential.     At  a  dis- 
tance of  over  four  feet  from  the  patient  this  mode  of  infection  is  no 
longer  possible.     Again,  this  danger  is  still  more  reduced  by  the 
fact  that  not  all  individuals  afflicted  with  pulmonary  tuberculosis 
have  bacilli  in  their  saliva;  also  the  time  the  physician,  nurse,  or 
friend  need  to  be  in  close  proximity  to  the  patient  is  rarely  longer 
than  a  few  moments. 

Bearing  all  these  points  in  mind,  we  may,  after  all,  say  that  with 
a  clean,  conscientious  consumptive,  with  a  faithful  nurse,  and  intel- 
ligent friends  and  relatives  about  him,  the  danger  of  his  communi- 
cating his  disease  to  others  is  very  small  indeed. 


m 


■i'u 

I 'it} 

4 


i  ;■!■ 
I 


: 


Compul- 
sory; regis- 
tration of 
tuberculous 
patients.        fessioil. 


i^ 

^ 


CHAPTER    V. 

PUBLIC    PROPHYLAXIS    IN    REGARD    TO   TUBERCULOSIS 

IN   MAN. 

We  will  now  consider  the  duties  of  the  sanitary  authorities  and 
the  general  government  in  regard  to  prophylaxis. 

We  have,  I  believe,  pointed  out  all  that  can  reasonably  be  ex- 
pected from  the  tuberculous  patient  and  those  who  surround  him, 
in  being  instrumental  to  stop  the  spread  of  this  disease.  What 
remains  must  be  done  by  the  sanitary  authorities,  aided  by  the 
good-will  of  the  physician,  especially  the  general  practitioner.  It  is 
he,  under  whose  observation  come  the  greatest  number  of  cases  of 
pulmonary  tuberculosis,  who  is  most  likely  to  discover  them  in  the 
incipient  state. 

Experience  has  demonstrated  that  compulsory  registration  or 
reporting  tuberculous  cases  finds  little  favor  with  the  general  pro- 
The  controversy  which  went  on  between  the  Board  of 
Health  of  the  City  of  New  York  and  the  medical  profession  at 
large  of  that  city  is,  perhaps,  the  best  proof  that  the  time  for  such 
radical  measures  has  not  come  yet.  If  we  succeed,  if  not  in  stamp- 
ing out,  at  least  in  reducing  in  a  marked  degree,  the  mortality  from 
phthisis  pulmonalis  without  resorting  to  any  measures  unwelcome 
to  the  medical  profession  and  the  laity  alike,  so  much  the  better. 
But  to  attain  this  end  a  co-operation  of  the  sanitary  authorities — 
government,  States,  county,  or  city  boards  of  health  and  all  medi- 
cal practitioners — is  indispensable.  It  should  be  made  possible 
for  the  general  practitioner  to  send  any  suspected  sputum  to  his 
respective  health  board  for  bacteriological  verification.  He  should 
be  provided  with  circulars  issued  by  the  board  to  give  instructions 
to  the  patient,  his  family,  and  friends.  These  circulars  will  be 
placed  by  the  medical  attenda.it  in  the  hands  of  such  person 
among  the  friends  of  his  patients  as  he  can  trust  to  carry  out  his 
instructions. 

If  the  physician  thinlcs  it  best,  he  will  give  the  instructions  to  the 
patient  directly.    If  this  latter  be  refractory,  insane,  or  too  ignorant, 

S6 


PUBLIC    PROPHYLAXIS. 


57 


and  his  family  or  friends,  from  some  reason  or  other,  are  unable  to 
prevent  him  from  disseminating  his  disease  by  promiscuous  ex- 
pectorating, it  should  become  the  duty  of  the  physician  to  report 
the  case  to  the  respective  sanitary  authorities,  who  should  effect 
proper  restriction,  or,  if  necessary,  isolation. 

The  strictest  supervision  on  the  part  of  the  board  of  health   in^f^^^Jj',*!"" 
regard  to  tuberculosis  should  be  exercised  over  insane  asylums,  [,'°"j^,^",''„„ 
prisons,   cloisters,    large  boarding-schools,  and  all  places  where  ofj"f"c[fo„. 
many  people  are  constantly  confined  to  a  relatively  small  space. 
The  statistics  from  all  over  the  world  show  that  the  mortality  from 
pulmonary  tuberculosis  in  these  places  has  been  higher  than  any- 
where else.'     My  personal  visits  to  some  otherwise  well-regulated 
prisons  and  similar  institutions  have  convinced  me  of  the  need  of 
more  serious  attention  to  this   matter.     A  most  reconimendable 
innovation  in  this  respect  is  the  projected  convict  camp  of  tuiieicu- 
lous  prisoners  of  the  State  of  Alabama. 

In  many  cities  tuberculosis  seems  to  cling  to  ce  n  localities 
and  houses  owing  to  the  nature  of  their  construction.  Tlu  dis- 
ease appears  in  a  veritable  endemic  form,  either  from  tlic  fa(  t  that 
careless  tuberculous  patients  have  lived  for  years  in  these  hon  <  - 
or  from  the  equally  important  fact  that  the  soil  on  which  these 
houses  have  been  built,  or  the  manner  in  which  they  have  been 
constructed,  is  of  a  nature  to  retain  the  tuberculous  infection 
indefinitely.  That  this  is  so  has  been  shown  by  the  report  of 
Professor  Biggs,-  of  the  Health  Board  of  New  York,  and  the  inter- 
esting works  on  this  subject  by  Dr.  Flick,^  of  Philadelphia. 

When  a  thorough  sanitary  overhauling  does  not  suffice  to  stamp 
out  these  centres  of  infection,  the  destruction  of  such  dwellings 
seems  the  only  remedy. 

The  circulars  issued  by  the  board  of  health*  in   regard  to  any  ciicuiaisor 

.  .  •  1  1   1  1        r  instriictioii 

disease,  but  especially  m  regard  to  consumption,  should  be  framed  aiKi  free 
in  clear,  precise,  untechnical,and  comprehensible  language.     Theyiion. 
should  call  attention  to  the  danger  from  an  unclean,  unscrupulous 
consumptive,  and  explain  wherein  this   danger  lies  and  how  to 
avoid  it.     But  the  circular  should  explain  also  that,  if  proper  pre- 

'  Cornet,  "  Zeitschrift  filr  Hygiene,"  vol.  \l,  p.irt  I,  iSSi). 

'  l^iggs,  "  Tlic  Action  of  the  Health  Department  in  Rehition  to  Pulmonary  Tuber- 
culosis."    A  report,  1897. 

»  Flick,  "  The  Contagiousness  of  Phthisis,"  1888. 


iijl' 


i 


Mi 


:'M 


.1'; 


!  I 


ill 


58 


PULMONARY   TUBERCULOSIS. 


cautions  are  taken  there  is  no  danger  in  associating  with  such  a 
patient.  Not  to  frighten  very  impressionable  natures,  the  circu- 
lar should  .state  that  pulmonary  tuberculosis  is  one  of  the  most 
curable  and  frequently  cured  diseases,  for  this  has  been  amply 
proved  ;  and  the  earlier  the  patient  puts  himself  under  the  doctor's 
care  the  more  chance  has  he  for  an  early  and  complete  recovery. 
Such  circulars  should  be  freely  distributed,  and  especially  in  the 
densely  crowded  districts  of  large  cities. 

To  the  poor  a  free  disinfection  by  the  health  authorities  should 
be  held  out  as  an  inducement  to  avail  themselves  of  such  an  oppor- 
tunity. 

The  disinfection  of  the  rooms  occupied  by  a  consumptive  should 
not  only  take  place  after  his  demise,  but  should  also  be  made  ob- 
ligatory at  stated  intervals  during  his  life-time.  The  method  indi- 
cated by  Novy  and  Waite  in  the  "Medical  News"  of  May  21, 
1898,  seems  to  me  most  practical  and  recommendable:  (i)  All 
cracks  or  openings  in  the  plaster  or  in  the  floor,  or  about  the  door 
and  windows,  should  be  caulked  tight  with  cotton  or  with  strips  of 
cloth.  (2)  The  linen,  quilts,  blankets,  carpets,  etc.,  should  be 
stretched  out  on  a  line  in  order  to  expose  as  much  surface  to  the 
disinfectant  as  possible.  They  should  not  be  thrown  into  a  heap. 
Books  should  be  suspended  by  their  covers,  so  that  the  pages  will 
fall  open  and  be  freely  exposed.  (3)  The  walls  a  id  the  floor  of  the 
room,  and  the  articles  contained  in  it,  should  be  thoroughly  sprayed 
with  water.  If  masses  of  matter  or  sputum  are  dried  down  on  the 
floor,  they  should  be  soaked  with  water  and  loosened.  No  vessel 
of  water  should,  however,  be  allowed  to  remain  in  the  room.  (4) 
One  hundred  and  fifty  centimetres  (five  ounce.s)  of  the  commercial 
forty-per-cent.  solution  of  formalin  for  each  one  thousand  cubic 
feet  of  space  should  be  placed  in  the  distilling  apparatus  and  be 
distilled  as  rapidly  as  possible.  The  keyholeand  spaces  ab-nt  the 
door  should  then  be  packed  with  cotton  or  cloth.  (5)  Tin  room 
thus  treated  should  remain  closed  at  least  ten  hours.  If  there  is 
much  leakage  of  gas  into  the  surrounding  rooms,  a  second  or  third 
injection  of  formaldehyde  at  intervals  of  two  or  three  hours  should 
be  made. 

Dispensaries  should  distribute  suitable  pocket-spittoons  gratui- 
tously to  their  very  poor  tuberculous  patients.  Those  able  to  pay 
for  them  should  be  treated  only  under  the  condition  that  they 
provide  themselves  with  such  pocket-flasks. 


11 


PUBLIC    PROPHYLAXIS. 


59 


Each  community  should  have  health  ordinances  to  suit  its  own  Health 

...  Ai  i-i-  r  •  r  ordinances. 

conditions.  A  place  which  is  a  favorite  resort  for  pulmonary 
invalids  will  require  much  more  stringent  rules  in  regard  to 
boarding-houses  and  hotels  than  the  average  place.  To  put  in 
public  conveyances,  halls,  theatres,  churches,  etc.,  placards  making 
spitting  on  the  floor  a  punishable  offense  will  prove  a  good  thing 
everywhere.  If  it  does  not  deter  all  the  spitters  from  expectorating 
wherever  they  please,  it  will  deter  some. 

In  Denver  the  City  Improvement  Society  has  sent  out  the 
following  note  to  ail  physicians  residing  in  the  city :  "Realizing 
that  physicians  can  do  more  than  any  one  power  to  prevent  the 
spread  of  consumption,  and  to  insure  sanitary  reform  in  the  matter 
of  non-expectoration  on  the  sidewalks,  to  the  physicians  of  the 
city  we  therefore  appeal  for  co-operation,  that  by  instructing  their 
patients  not  to  spit  on  the  sidewalks  we  may  have  a  cleaner  and 
more  healthful  city." 

The  city  attorney  has  also  prepared  a  bill,  as  follows :  "  Sec- 
tion I.  It  shall  be  unlawful  for  any  person  to  spit  upon  the  floor 
or  any  part  of  any  street-car  or  elevator  within  the  city  of 
Denver.  Section  2.  Any  person  violating  the  provisions  of  this 
ordinance  shall,  upon  conviction,  be  fined  not  less  than  three  dollars 
nor  more  than  five  dollars  for  each  offense ;  and  the  conductors  of 
all  street-cars  and  the  pilots  of  all  elevators  are  hereby  authorized 
and  empowered  to  enforce  the  terms  of  this  ordinance." 

An  excellent  method  of  educating  the  public  in  regard  to  the  societies 

^  I  o  lor  the  pre- 

necessitv  of  preventive  measures  to  stop  the  spread  of  tuberculosis  vention  of 
is  the  formation  of  societies  for  this  purpose.  They  exist  now  in^'^- 
nearly  all  civilized  countries,  and  have  done  some  very  good  work- 
already.  These  societies  are  composed  of  laymen  and  medical 
men,  and  their  purpose  is  usually  twofold.  The  medical  members 
deliver  public  lectures  or  compose  tracts  for  distribution.  The 
Pennsylvania  Society  for  the  Prevention  of  Tuberculosis,  for 
exam[)le,  distributed  last  year  50,000  tracts  entitled  "  1  low  to 
Avoid  Contracting  Tuberculosis,"  40,000  tracts  entitled  "  How 
Persons  Suffering  from  Tuberculosis  Can  Avoid  Giving  the  Disease 
to  Others,"  and  10,000  tracts  entitled  "How  Hotel-keepers  Can 
Aid  Ml  Preventing  the  Spread  of  Tuberculosis."  This  year,  a 
circular,  setting  forth  the  "  Predisposing  Causes  of  Tuberculosis 
and  How  to  Avoid  or  Overcome  Them,"  has  been  extensively 
circulated  by  the  same  society. 


'  I 


11 


i\\ 
ii 


It; 


ii 


'  i 


60 


PULMONARY   TUBERCULOSIS. 


. 


Duties  of 
the  school 
physician 
III  rc'Raril  to 
tuberculo- 
sis. 


Lack  ot 
hyKieiie  in 
railway- 
and  street- 
cars. 


The  second  very  laudable  purpose  of  some  of  these  societies  is 
the  end'^avor  to  establish  sanatoria  for  the  treatment  of  the 
tuberculous  poor.  Of  the  importance  of  such  institutions  as 
preventive  factors  in  the  prophylaxis  of  tuberculosis  we  will  speak 
directly. 

An  Association  for  the  Prevention  of  Consumption  and  Other 
Forms  of  Tuberculosis  was  founded  in  London  during  the  summer 
of  1898,  and  more  recently  a  similar  association  was  organized  in 
Chicago  and  one  in  Durham,  England.  The  object  and  scope  of 
these  associations  are  similar  to  those  of  the  Pennsylvania  society. 

The  place  where  the  coming  generation  should  receive  most  of 
its  hygienic  education  is  the  public  school.  There  the  children 
should  be  taught  all  that  is  conducive  to  health,  and  also  how  to 
avoid  all  that  is  unsanitary.  The  intelligent  boy  or  girl  will  com- 
prehend, as  well  as  the  grown  person,  why  one  should  not  expecto- 
rate except  in  a  proper  receptacle.  In  our  chapter  on  prophylactic 
treatment  we  will  speak  more  fully  of  the  duty  of  the  public  school 
in  the  prevention  of  consumption.  I  wish  to  state  here  only  that 
the  school  physician  (and  every  school  should  have  one),  charged 
with  examining  the  children  every  morning  for  contagious  diseases, 
such  as  scarlatina,  variola,  diphtheria,  and  measles,  should,  on 
discovering  a  child  developing  tuberculosis,  insist  upon  the  exclu- 
sion of  this  pupil  from  the  public  school.  Besides  being  a  menace 
to  the  other  pupils,  the  child  will  have  no  chance  of  getting  well 
while  daily  attending  .school  in  a  crowded  classroom. 

Quite  an  important  factor  in  the  propagation  of  tuberculosis  has 
always  seemed  to  me  the  unhygienic  mode  of  construction  and 
management  of  railway  passenger-cars,  and  especially  of  the  sleep- 
ing-cars, which  are  extensively  used  in  the  United  States  by  pul- 
monary invalids  in  search  of  warmer  climes.  The  unsanitary 
arrangement  of  these  sleeping-cars  must  be  evident  to  any  one  who 
has  given  the  matter  attention.  Only  a  few  months  ago,  when 
going  south,  I  had  three  traveling  companions  in  the  more  ad- 
vanced sta{7"es  of  pulmonary  tuberculosis,  one  unable  to  leave  his 
berth  during  the  daytime.  They  were  all  male  patients,  and  with 
them  the  rest  of  the  male  passengers,  the  conductor,  the  trainman, 
and  the  colored  porter  enjoyed  the  privilege  of  one  drinking-glass. 
The  patients  coughed  and  expectorated  a  good  deal,  sometimes 
hitting  and  sometimes  mis.sing  the  small  hole  in  the  flat  cuspidor, 
which  contained  no  liquid  whatsoever.     One  may  draw  hisconclu- 


PUBLIC    PROPHYLAXIS. 


6l 


sions  from  this  as  to  the  safety  of  the  innocent  traveler  who  enters 
this  car  having  a  slight  bronchitis,  being  in  a  condition  of  acci- 
dentally enfeebled  health,  or  with  a  natural  predisposition  to  con- 
sumption. A  few  days  later  I  returned  in  the  same  car,  and  I 
am  sure  it  had  not  been  disinfected  since  I  traveled  in  it  south- 
ward. 

Now,  I  am  told  that  it  is  impossible  to  hinder  a  consumptive  from 
entering  a  Pullman  car,  and  that  if  there  were  a  law  whereby  he 
could  be  prevented  from  doing  so  it  would  be  well-nigh  impossible 
to  enforce  it.  I  grant  this  to  be  true,  but  if  our  wealthy  railroad 
corporations  owning  lines  which  habitually  carry  consumptives  to 
and  from  health  resorts  could  be  induced  to  run  ambulance-cars, 
especially  adapted  to  the  purpose,  a  good  deal  of  danger  now  exist- 
ing would  be  done  away  with.  If  these  ambulance-cars  would 
offer  to  the  traveling  consumptive  only  twice  the  ordinary  breathing- 
space,  and  if  the  railroad  company  would  be  magnanimous  enough 
to  have  a  trained  nurse  in  charge  of  each  car,  the  accommodations 
thus  offered  would  be  eagerly  sought  by  all  invalids;  even  an 
additional  price  would  not  deter  the  average  patient  from  making 
use  of  this  mode  of  travel,  which  would  certainly  lessen  materially 
the  many  discomforts  from  which  he  has  to  suffer  in  the  ordinary 
sleeping-car.  Wire  mattresses,  leather  cushions,  linen  curtains, 
special  cuspidors,  and  linoleum  instead  of  carpets,  with  better 
ventilation  generally,  could  make  of  such  a  "Pullman"  a  model 
ambulance-car,  easily  disinfected,  and  a  credit  to  the  respective 
company.  But  a  regular,  thorough  cleaning  and  disinfection  of  all 
passenger-cars,  even  of  our  street-cars,  at  stated  intervals  should 
be  made  obligatory. 

I  am  happy  to  learn  that  Mr.  E.  A.  Jewett,  the  Assistant  General 
Superintendent  of  the  Pullman  Palace- Car  Company,  has  recently 
issued  directions  for  disinfecting  the  Pullman  cars  by  formalde- 
hyde vapor. 

Equally  important  seems  to  me  the  regular  disinfection  of  all  pisinfet- 
localities  in  which  large  gatherings  take  place,  such  as  theatres, theatres, 
churches,  music-halls,  etc.  I  learn  that  some  of  the  New  Orleans 
theatres  have  already  distinguished  themselves  by  the  happy  inno- 
vation of  disinfecting  their  entire  building,  after  each  performance, 
with  formaldehyde  gas.  This  practice  is  certainly  most  highly  to 
be  recommended,  and  should  become  obligatory  in  all  civilized 
communities. 


-m 

'■W 

iiitriMifiil 

il 


1\ 


•A\ 


62 


PULMONARY   TUBEKCULOSIS. 


Street 
sweepiliK 
:iii(l  tiuiiii.'d 
dresses. 


Disposal  of 
the  dead. 


Streets  should  never  be  swept  without  having  been  previously 
thoroughly  .sprinkled.  Professor  Schrotter  calls  the  sweeping  of 
unsprinkled  streets  and  its  accompanying  raising  of  clouds  of  dust 
a  crime  toward  one's  fellowmen. 

But,  to  my  mind,  equally  dangerous  is  dame  Fashion,  when  she 
decrees  that  our  ladies  shall  wear  long  or  trained  street-dresses. 
To  walk  and  breathe  behind  a  lady  dragging  her  dress  over  dusty, 
dirty  sidewalks,  often  dotted  with  deposits  of  buccal,  bronchial,  and 
pulmonary  secretions,  sometimes  containing  the  various  pathogenic 
microbes,  at  others  mixed  with  the  juice  of  the  leaves  of  Nicotiaita 
tabacnm,  must  be  dangerous  to  the  health  of  every  one.  How  I 
pity  the  poor  woman  who  is  afterward  obliged  to  clean  these  skirts, 
soiled  with  an  accumulation  of  filth,  dust,  and,  alas!  too  often  with 
disease-producing  germs!  If  our  ladies  will  not  soon  awaken  to 
the  danger  of  this  mode  of  dress,  I  should  certainly  favor  city 
ordinances  prohibiting  the  wearing  of  trailing  dresses  in  public 
streets. 

A  chapter  on  prophylaxis  of  tuberculosis  would  not  be  complete 
without  mentioning  the  danger  arising  from  the  present  most 
universal  mode  of  the  disposal  of  the  dead.  In  connection  with 
the  disposal  of  the  sputum,  I  have  already  referred,  on  page  50,  to 
the  experiments  of  Lortet  and  Despeignes,  whereby  it  was  demon- 
strated that  earth-worms  are  capable  of  ingesting  and  ejecting  the 
tubercle  bacilli  without  the  micro-organisms  losi.ig  their  virulence. 
Other  experimenters,  such  as  Galtier,'  of  Lyons,  showed  that  the 
bacillus  of  tuberculosis  resisted  putrefaction  for  several  months, 
Gartner"  buried  the  bacillus  for  one  year,  and  it  retained  its 
infectious  property,  and  Schottlius  even  claims  that  it  resisted 
putrefaction  for  two  years.  In  view  of  these  and  numerous  other 
proofs  of  the  danger  of  burying  those  who  have  died  from  tuber- 
culous diseases,  the  Third  Congress  for  the  Study  of  Tuberculosis, 
held  in  Paris  in  1894,  adopted  resolutions  asking  for  obligatory 
disinfection  of  the  bodies  of  diseased  tuberculous  individuals.  A 
motion  for  recommending  obligatory  cremation  of  such  bodies  was 
not  carried.  Leaving  the  religious  objection  to  cremation  out  of  con- 
sideration, it  seems  to  me  that  the  objection  raised  from  a  medico- 
legal   standpoint    (inability    to    discover    jioison    after   cremation) 


'  Galtier,  "Congrfis  pour  r^tude  de  la  Tuberc,"  p.  213,  Paris,  Oct.,  1893. 
^  Gilrtner,  Congress,  ileriiti,  18S7. 


PUBLIC    PROPHYLAXIS. 


63 


can  hardly  have  any  weight  in  a  case  of  death  from  a  chronic 
tuberculous  disease.  As  one  of  the  means  of  stamping  out  tuber- 
culosis in  the  human  race,  I  would  certainly  favor  the  cremation 
of  all  bodies  of  individuals  having  died  of  a  tuberculous  disease. 
Thalassic  submersion  as  a  means  for  the  disposal  of  the  dead  seems 
also  preferable  to  the  methods  now  most  universally  in  vogue.' 

We  have  not  yet  touched  upon  the  social  causes  in  the  propaga- 
tion of  tuberculosis.  These  are  numerous,  but  we  will  speak  only 
of  those  which  can  be  remedied  by  the  sanitary  authorities.  Dr. 
Hermann  Weber,  cf  London,"  in  a  very  able  paper  read  before  the 
Tenth  Medical  Congress  in  Berlin,  on  "The  Influence  of  Climate, 
Soil,  and  Social  Conditions  on  the  Occurrence  and  Course  of  Pul- 
monary Tuberculosis,"  speaks  of  the  danger  of  badly  ventilated 
workrooms  and  factories,  where  all  sorts  of  dust  is  inhaled, 
unhealthy  sleeping-rooms,  etc.,  in  the  furtherance  of  this  disease. 
Promiscuous  spitting  should  be  especially  prohibited,  and  appro- 
priate spittoons,  such  as  Predoehl's,  should  be  placed  in  suflficient 
numbers  in  all  factories,  workshops,  etc. 

A  sanitary  supervision  of  factories,  workshops,  and  stores,  with  a 
view  of  securing  hygienically  constructed  and  managed  places  where 
the  workers  have  to  toil,  is,  of  course,  essential.  In  all  such  indus- 
tries where  the  inhalation  of  organic  or  metallic  dust  seems  to  be 
inevitable,  the  workers  should  be  provided  with  respiratory  masks, 
such  as  are  in  use  in  some  of  the  factories  in  luirope. 

The  regulation  of  working-hours,  especially  for  women  and 
children,  will  also  lead  to  a  reduction  of  the  mortality  from  tuber- 
culosis. No  one  is  more  prone  to  become  consumptive  than  the 
overworked  individual  whose  environments  are  the  contrary  to 
what  is  considered  sanitary. 

Syphilis  is  not  infrequently  a  predisposing  cau.se  to  pulmonary 
tuberculosis.  To  regulate  prostitution,  and  thus  diminish  the  dan- 
ger of  venereal  infection,  by  humane  but  strict  laws,  must,  of  neces- 
sity, become  a  portion  of  the  public  prophylaxis  of  consumption. 

Alcoholism  predisposes  to  pulmonary  tuberculosis  to  a  still  higher 
degree.     Children  of  alcoholic  parents  are  ])articularly  susceptible 


'  H.  D.  l.iihty,  "  jouinal  ,)f  Aincricaii  Med.  Association,"  Nov.  26,  1898. 

^  Weber,  II.,  "  Oberden  Eiiiiluss  derkliniatiscbeii  lioden-  uiid  gesellschaftliclieii  \'cv- 
li;Utnisse  niif  <len  Vcilauf  der  l.iinneiilulierkulose,  etc.,"  "  .Miiiiclu'iipr  iiu'd.  Wocli  ii- 
schrifl." 


Simie  social 
causes  in 
llie  propa- 
><:atioii  of 
liiberciilo- 
sis. 


1*1- 


it 


J' 


64 


PULMONARY   TUHKRCULOSIS. 


to  tubercular  diseases.  Legrain,  in  his  excellent  work  on  "  De- 
generescence  et  Alcoolisme,"  says  that  he  found  tuberculosis  pre- 
vailing 32  times  in  215  alcoholic  families.  To  combat  alcoholism 
must  be  the  work  of  the  statesman  and  sanitarian.  With  the 
diminution  of  the  consumption  of  alcohol  there  will  be  a  corre- 
sponding reduction  in  the  mortality  from  pulmonary  tuberculosis. 
The  following  table,  compiled  by  [Archibald  Ken  Chalmers, 
M.D.,  D.P.H.,'  showing  the  comparative  mortality  of  individuals, 
occupied  in  the  various  pursuits  of  life,  will  be  the  best  guide  to 
the  sanitary  authorities  as  to  where  intervention  is  most  needed: 


Agriculuirist, 

Engiavir  (Artist  class),     .    . 

Shopkeeper, 

Butcher,  

Commercial  Clerk,  .    . 

Watchmaker,      

Sa.liller 

Shoemaker 

Draper, 

Tailor, 

Hairdresser, 

Tobacconist,  Tobacco  Manu- 
facturer,   

H&tter 

Musician, 

liookhinder, 

Printer, 


Phthisis. 


106 
146 
172 

195 
21S 

243 
248 
256 
260 

271 
276 

280 

322 

325 
326 


OrHi:K  Um- 

KASKS  OI' 

Rhspirahon. 


"5 

133 
17;; 
209 
172 

193 
169 
181 
181 
195 
213 

181 
210 
200 
218 
214 


UOTII 

T(>GKTii!:i;, 


221 

279 

350 
404 

390 

427 

437 
441 
466 
489 

461 

511 

522 

543 
540 


Pi.K  Cknt.  or 

I'HIHISJS 

K)    All.    UlS- 

KASKS  Ol' 

Rkspiration. 


48.0 

52.3 
49.1 

483 

55-9 
S4.8 

59-5 
58.6 
59-0 

5f;.2 

56.4 

60.7 

589 
61.7 

59-9 
60.4 


Coal-smoke  ^"  somc  cities  vigorous  measures  against  the  production  of 
nuisance,  quantities  of  coal-smoke  would  doubtlessly  render  the  atmosphere 
purer  and  the  diseases  of  the  respiratory  organs  rarer.  In  England 
there  exists  a  Coal-smoke  Abatement  Society,  which  has  for  its 
object  to  combat  the  smoke  nuisance  and  to  enforce  existing  laws 
against  black  smoke.  They  are  trying  now  to  have  a  law  passed 
making  it  illegal  for  any  house  to  be  built  without  being  fitted  with 
proper  smoke-consuming  appliances. 

Damp,  badly  ventilated,  and  dark  habitations  seem  to  favor  the 
development  of  tuberculous  diseases,  and  a  well-drained  spot  with 


'  "  The  Causation  of  Tuberculosis  and  its  Prevention  by  Legislation,"  "  The  Prac- 
titioner," London,  June,  1S98. 


PUnr.IC    PROPHYLAXIS. 


65 


porous  soil  will  always  be  the  best  place  to  build  a  dwelling,  hos- 
pital, or  sanatorium  for  consumptives.  Another  urgent  need  in  our 
large  cities,  as  urgent  as  sanatoria  for  the  consumptive  poor,  is 
model  tenement  houses.  So  long  as  the  poor  arc  housed  by  hun- 
dreds in  dark,  filthy,  and  badly  ventilated  buildings,  so  long  will  it 
be  impossible  to  stamp  out  consumption. 

Of  what  great  importance  it  is  to  our  rising  generation  that  only 
the  most  sanitary  schools  and  colleges  should  be  built!  We  should 
be  as  anxious  to  give  our  children,  young  men,  and  young  women, 
during  their  school  life,  just  as  much  opportunity  of  developing  a 
sound,  vigorous  body  as  of  obtaining  culture  and  knowledge. 


II 


i 


CHAPTKR   VI. 

SANITARY    LAWS   CONCERNING   THE   PREVENTION   OF 
BOVINE   TUBERCULOSIS. 

We  come  now  to  another  important  class  of  preventive  measures 
to  combat  the  spread  of  tuberculosis  in  man  ;  I  speak  of  those 
directed  toward  the  suppression  of  tuberculosis  in  our  domestic 
animals,  especially  in  cattle. 

The  danger  from  tuberculous  meat  and  milk  has  been,  I  fear, 
underestimated  in  years  past.  Many  authors  have  considered, 
and  consider  yet,  the  dissemination  of  the  germs  contained  in  the 
carelessly  deposited  sputum  of  tuberculous  patients  the  only  im- 
portant factor  in  communicating  the  disease  to  others  ;  and  I  am 
willing  to  admit  that  I,  also,  formerly  adhered  to  the  same 
opinion.  But  I  recently  undertook  to  trace,  in  as  many  cases  as  it 
was  possible  from  the  ])ublished  history,  the  etiology  as  to  ante- 
cedents, environments,  and  personal  and  family  history,  and  I  was 
astonished  to  find  in  how  large  a  number  one  was  justified  to  ex- 
clude the  inhalation  of  bacilli  as  the  etiological  factor.  A  farmer, 
cowboy,  gardener,  wood-chopper,  or  any  other  individual  living  in 
the  open  air  most  of  the  time,  residing  in  an  isolated  district 
where  consumption  is  rare,  if  not  unknown,  with  no  family 
history  of  tuberculosis,  sickens  and  dies  of  j)hthisis  pulmonalis. 
Now,  while  it  is  true  that  primary  intestinal  tuberculosis  is  of 
relatively  rare  occurrence  in  the  adult,  we  can  account  for  this 
by  the  fact  that  he  rarely  takes  raw  or  unsterilized  milk  as 
his  exclusive  nourishment,  which  may  be  the  case  with  an 
unfortunate  child  whose  delicate  intestinal  epithelium,  as  we  ex- 
plained before,  becomes  the  abiding-place  of  the  tubercle  bacillus 
contained  in  countless  quantities  in  every  meal  he  gets.  In 
the  adult  the  ingested  bacillus  seems,  in  the  majority  of  cases,  to 
pass  through  the  lymphatic  system  into  the  circulation  of  the  blood, 
to  find  its  favorite  lodging-place  in  the  badly  ventilated  apices  of 
the  lungs. 

It  is  well  known  that    the  bactericidal   quality  of  the  gastric 

66 


SANITAKY    LAWS   TO    PREVENT    IIOVINK   TUIIERCUI.OSIS. 


67 


secretions  is  insufficient  in  refjard  to  the  germ  of  tuberculosis.  The 
only  defense  against  this  mode  of  invasion  seems  to  lie  in  the  good 
phagocitic  power  of  the  blood  of  the  healthy  individual.  Now, 
when  we  consider  that  milk,  butter,  and  meat  of  cattle  constitute 
m  s!  important  ami  most  universally  used  articles  of  food  for  man, 
and  how  relatively  recently  laws  in  regard  to  tuberculosis  have 
been  enacted  at  all,  and  in  how  many  States  such  laws  do  not  exist 
or  are  but  feebly  enforced,  I  think  it  is  not  surprising  when,  in 
looking  into  the  e.xact  etiology  of  many  cases  of  pulmonary  tuber- 
culosis, we  find  that  a  very  large  number  must  h?ve  been  caused 
by  the  ingestion  and  not  by  the  inhalation  of  the  bacillus. 

After  arriving  at  this  conclusion  I  was  much  gratified,  when  on 
a  r'  'cnt  visit  to  Dr.  von  Ruck's  sanatorium  in  Asheviile,  North 
(.'arnli'ia,  to  hear  his  opinion  in  this  matter.  Me  told  me  that,  to 
judge  from  the  carefully  kept  history  of  many  thousand  cases  from 
all  over  the  United  States,  which  have  come  under  his  observation, 
the  majority  of  cases  of  pulmonary  tuberculosis,  in  his  opinion,  had 
their  origin  in  the  ingestion  of  tuberculous  food  of  some  kind. 
Dr.  V.  W.  Smith,  of  the  Tuberculosis  Committee  of  the  State  Board 
of  Health  of  New  York,  whose  experience  in  the  matter  of  prophy- 
lactic measures  in  regard  to  tuberculosis  has  been  considerable, 
seems  to  be  of  a  similar  oi)inion,  for  he  writes  me:  "The  first 
great  step  toward  the  prophylaxis  of  tuberculosis  in  man  is  to 
stamp  out  the  disease  in  cattle."  Dr.  Martin,  of  the  Royal  Com- 
mission of  England,  says  :  "  The  milk  from  cows  with  tubercu- 
lous udders  posses.ses  a  virulence  which  can  only  be  described  as 
extraordinary." 

Even  the  geographical  distribution  seenis  to  pointto  the  fact  that^.         ,, 
the  bovine  race  is  in  a  large  measure  responsible  for  the  prevalence {Jy,'i,'j',',""f" 
of  tuberculosis  among  men.     In  a  very  able  paper,  read  before  the  [;",^,I[j[;,'Jis. 
American  Health  Association,  at  the  twenty-fifth  annual  meeting, 
heldat  Philadoipliiaon  October  26to  29,  1897,  Dr.  M.  P.  Ravenel,of 
the  Veterinary   Department   of    the    University  of  Pennsylvania, 
showed  that  in   northern   Norway,  Sweden,  Lapland,  and  Finland, 
where  reindeer  constitute  the  bulk  of  farm  animals;  about  Hudson 
Bay  and  in  the  islands  of  the  Pacific,  where  no  cattle  exist;   in  the 
Scottish  Hebrides,  Iceland,  and  Newfoundland,  where  there  are  only 
few  cattle,  tuberculosis  is  far  less  prevalent  in  man.     Particularly 
dangerous,  on  the  contrary,  seems  to  be  the  regions  where  cattle 
are  housed  and  the  people  live  in  close  pro.ximity  to  them,  as,  for 


lii 


III 


.■(4;-(,. 


68 


PULMONAKY   TUBEKCULOSIS. 


I  i 
I 


example,  in  Italy.  This  condition  caused  Perroncito  to  call  tuber- 
culosis "  the  scourge  of  man  and  beast." 

It  is  estimated  that  in  the  State  of  New  York  there  are  at  this 
time  no  less  than  75,ocK)  tuberculous  cows.'  I  am  not  prepared 
to  give  other  exact  .statistics,  I  think,  however,  it  is  usually 
estimated  that  at  least  five  per  cent,  of  all  milch-cows  are  tuber- 
culous. But  among  some  herds  of  high-bred  cattle  not  infre- 
quently fifty  per  cent,  are  found  to  be  suffering  from  tuberculosis. 
Let  us,  then,  in  our  war  against  this  disease,  divide  our  attention 
equa.'ly  between  the  bacilli  which  may  be  ingested  and  the  bacilli 
which  may  be  inhaled. 

Most  European  governments  have  realized  the  importance  of 
concerted  action  in  this  matter.  England  has  its  Royal  Commis- 
sion to  investigate  the  spread  of  tuberculosis  in  domestic  animals ; 
I'Academie  Nationale  de  Medecine  of  France  has  its  permanent 
Section  on  Veterinary  Medicine,  which  has  done  much  in  the 
direction  of  bovine  legislation;  Germany  has  most  rigorous  laws 
and  regulations  in  connection  with  bovine  tuberculosis. 

Here  in  the  United  States,  owing  to  our  geographical  and 
sutes''"^^  political  situation,  we  have  no  uniform  laws  regarding  bovine 
tuberculosis,  much  less  regarding  tuberculosis  in  man.  To  ascer- 
tain the  true  condition  of  prophylaxis  in  regard  to  tuberculosis,  I 
addressed,  last  year,  letters  of  inquiry  to  all  the  secretaries  of  the 
State  boards  of  health  of  all  the  States  and  Territories  of  the 
Union,  and  to  the  health  officers  of  forty  of  the  largest  cities,  and 
reported  the  results  of  my  inquiry  to  the  Section  on  State 
Medicine  at  the  Forty-eighth  Annual  Meeting  of  the  American 
Medical  Ass  jc'ation."     I  quote  the  following  from  my  report: 

Alabama. — No  laws  or  regulations  concerning  tuberculosis  in 
man  or  beast,  and  no  circulars  issued. 

Arkansas. — No  laws,  regulations,  or  circulars  concerning  tuber- 
culosis. Dr.  Jennings,  the  executive  officer,  writes  that  the  State 
not  having  made  any  appropriation,  the  board  is  handicapped  for 
want  of  funds. 


TubercnlO' 
sis  laws  in 


'  Cassidy  and  Siiiilli,  "Tuberculosis:  It  is  llie  Duty  of  tlie  .Slate  to  Suppress  tlie 
Greatest  Destroyer  of  the  Human  Race."     New  York,  February,  1897. 

"  Knopf,  "  The  Present  Status  of  Preventative  Means  against  tlie  Spread  of  Tuber- 
culosis in  the  Various  States  of  the  Union  Ciilically  Reviewed,"  "  Journal  of  the  Atner. 
Med.  Assoc,"  Oct.  30,  1897. 


SANITARY    LAWS   TO    PREVENT    BOVINE   TUBERCULOSIS. 


69 


California. — Good  bovine  laws  and  regulations;  circular  issued 
on  consumption. 

Colorado. — Good  bovine  laws  and  regulations,  and  a  special 
circular,  "  How  to  Prevent  the  Spread  of  Consumption  in  Colo- 
rado." 

Connecticut. — Good  bovine  laws  enforced  by  the  State  Board  of 
Agriculture,  and  a  circular  on  "  Consumption  :  Its  Cause  and  Means 
of  Prevention." 

Delaware. — Circular  on  the  prevention  of  consumption. 

District  of  Columbia. — Only  one  law  in  regard  to  tuberculosis, 
which  forbids  the  sale  of  milk  that  may  be  tuberculous.  No  cir- 
culars or  public  notices. 

Georgia. — There  was  formerly  a  State  board  of  health,  but  it 
has  been  allowed  to  become  ext'nct  for  lack  of  appropriation. 

Idaho. — No  State  board  of  health.  Provision  is  made  for  the 
appointment  of  health  officers  by  the  various  boards  of  county 
commissioners,  but  they  are  answerable  to  the  local  authority 
only. 

Illinois. — The  board  has  never  passed  any  laws  or  resolutions 
concerning  tuberculosis,  and  no  circulars  have  been  issued. 

Indiana. — No  bovine  laws  yet,  but  the  question  is  agitated.  The 
board  issues  two  thousand  quarterly  bulletins  free  to  all  county, 
city,  and  town  health  officers,  and  to  others  who  may  subscribe 
for  them. 

lo'iva. — The  board  is  very  active  in  educating  physicians  and 
laity  in  regard  to  tuberculosis,  and  is  enforcing  its  bovine  laws  with 
vigor. 

Kansas. — No  laws,  regulations,  or  circulars  concerning  tuber- 
culosis in  man  or  beast.  The  Legislature  failed  to  make  any  appro- 
priation and  the  State  veterinary  office  is  abolished. 

Kentucky. — For  want  of  appropriation  the  board  has  undertaken 
no  work  in  regard  to  bovine  tuberculosis,  but  a  circular  on  con- 
sumption has  been  issued. 

Louisiana. — Circulars  are  sent  to  physicians,  and  stations  for  the 
free  examination  of  sputum  have  been  established,  but  the  attempts 
of  the  board  to  secure  legislation  in  regard  to  bovine  tuberculosis 
have  been  thwarted  by  concert  of  action  on  the  part  of  the  ignorant 
and  prejudiced  Creoles,  who  have  almost  entire  control  of  the 
dairy  business. 

Maine. — The  cattle  commissioners  are  authorized  to  slaughter 


-    1 

'   in 


I     I 


70 


PULMONARY   TUBERCULOSIS. 


S- 


tuberculous  cattle  and  reimburse  the  owners,  and  the  board  has 
issued  a  circular  on  consumption. 

Maryland. — No  laws,  regulations,  or  circulars  on  tuberculosis. 

Massachusetts. — Five  cattle  commissioners  appointed  by  the 
governor  are  entrusted  with  the  suppression  of  bovine  tubercu- 
losis. A  circular  on  the  best  means  of  preventing  consumption  is 
issued. 

Michigan. — The  State  Live-stock  Commission  is  intrusted  with 
the  work  concerning  the  suppression  of  bovine  tuberculosis.  Cir- 
culars for  public  instruction  are  issued.  September  30,  1893, 
resolutions  were  adopted  to  include  consumption  in  the  official  list 
of  diseases  dangerous  to  the  public  health. 

Minnesota. — Good  bovine  laws.  I  received  no  report  in  regard 
to  provisions  concerning  tuberculosis  in  man. 

Mississippi. — No  laws,  regulations,  or  circulars  concerning  tuber- 
culosis in  man  or  beast.  With  the  reorganization  of  the  board 
better  work  is  hoped  for. 

Missouri. — No  answers  to  my  inquiries,  but  I  learn  from  the 
daily  paper  that  the  State  board  recommends  public  lectures  on  the 
question  in  the  more  populous  centres,  and  all  pupils  of  the  public 
schools  throughout  the  State  be  given  a  course  of  instruction  in 
the  causes  of  consumption  and  means  by  which  it  may  be  pre- 
vented. 

Montana. — No  State  board  of  health. 

Nebraska. — The  board  at  present  is  a  mere  licensing  body  with- 
out sanitary  powers. 

Nex^<  Hampshire. — No  special  regulations  on  the  prevention  or 
restriction  of  tuberculosis,  but  some  papers  on  the  subject  have 
been  printed.  In  1891  the  Legislature  enacted  a  law  creating  a 
State  Board  of  Cattle  Coiumissioners. 

Neiv  Jersey. — The  State  Board  of  Agriculture  enforces  the  bovine 
laws,  and  a  circular  on  consumption  has  been  issued. 

Neiv  Mexico. — The  territorial  board  ha.;  noticed  the  increase  of 
phthisis  among  natives  of  the  Territory  and  has  traced  many  cases 
to  an  exposure  to  possible  infection,  New  Mexico  being  a  favorite 
resort  for  consumptives.  Circulars  on  consumption  are  profusely 
distributed,  and  last  year  the  board  passed  resolutions  encouraging 
the  testing  of  domestic  animals  with  tubercuiine. 

Neiv  York. — Good  bovine  laws  not  very  rigidly  enforced  because 
the  State  appropriation  is  small.     Most  efficient  work  was  done  at 


SANITARY    LAWS    lO    PREVENT    BOVINE   TUBERCULOSIS. 


71 


first  by  the  Tuberculosis  Committee  of  the  board,  but  there  was  no 
appropriation  last  year,  in  spite  of  the  fact  that  it  has  been  demon- 
strated that  there  are  at  this  time  75,000  tuberculous  cows  in  the 
State.'  Circulars  like  those  of  the  New  York  City  board  have 
been  issued.  To  New  York  belongs  the  credit  of  having  done  the 
pioneer  work  in  educating  the  public  to  the  dangers  of  tuberculo- 
sis. The  State  board  requests  all  local  health  officers  to  i^egister 
name  and  address  of  every  person  suffering  from  tuberculosis 
within  their  respective  jurisdictions. 

North  Carolina. — No  laws,  regulations,  or  circulars  concerning 
tuberculosis  in  man  or  beast.- 

NortJi  Dakota. — No  laws,  regulations,  or  circulars  concerning 
tuberculosis  in  man  or  beast. 

Oliio. — No  bovine  laws.  A  circular  on  the  prevention  of  con- 
sumption has  been  issued. 

Oklahoma. — There  is  a  law  prohibiting  the  sale  and  use  of  milk 
from  cows  not  in  proper  condition  of  health.  Nothing  else  is  done 
in  regard  to  the  prevention  of  tuberculosis. 

Oregon. — No  State  board. 

Pennsylvania. — The  State  Live-stock  Sanitary  Board  is  entrusted 
with  full  power  to  suppress  bovine  tuberculosis.  The  board  of 
health  has  passed  resolutions  that  tuberculosis  be  added  to  the  list 
of  communicable  diseases  dangerous  to  the  public  health.  Circu- 
lars are  issued  and  the  Pennsylvania  Society  for  the  Prevention  of 
Tuberculosis  is  in  a  flourishing  condition,  although  it  does  not  re- 
ceive any  aid  or  encouragement  from  the  State. 

Rluhlc  Island. — Circulars  are  freely  issued.  Sputum  is  examined 
free  of  charge,  and  $10,000  yearly  is  expended  to  enforce  bovine 
regulations. 

South  Carolina. — No  bovine  laws.  Some  years  ago  circulars 
were  [)rinted  and  distributed,  but,  no  more  appropriation  for  this 
purpose  having  been  forthcoming,  nothing  is  now  done. 

South  Dakota. — There  is  a  law  providing  for  the  destruction  of 


'  Cassidy  and  Smitli,  "  Tuberculosis  :  It  is  tlie  Duty  of  tlie  Stale  to  Suppress  the 
Ciieatest  Destroyer  of  the  lliuuan  Race." 

'  Anil  to  tills  State  llock,  year  in  and  year  out,  thousands  of  tuberculous  invalids  in 
search  of  hcjitli.  Duriiij^  the  discussion  nu  this  subject  at  tin-  meeting  of  the  New  Vorl< 
Academy  of  Medicine,  of  May  5,  I.S9S,  Dr.  John  II.  (jirdncr  said  tliat  a  year  ago  he 
had  e.xperinienled  with  tubercuHiie  among  the  cattle  in  the  mountains  of  North  Carolina, 
and  had  found  tlieui  tul)eri;ulous  almost  without  exception. 


72 


PULMONARY    TUBERCULOSIS. 


) 


it 


tuberculous  animals  and  carcasses  ;  nothing  concerning  tubercu- 
losis in  man.     Provision  is  hoped  for  from  the  next  Legislature. 

Tennessee. — Circulars  on  the  prevention  of  tuberculosis  in  man 
and  beast  have  been  issued.  There  are  bovine  laws,  but  owing  to 
want  of  funds  the  board  has  been  deterred  from  formal  action  up 
to  this  time. 

Texas. — The  quarantine  department  is  the  highest  sanitary 
authority.  Its  powers  are  limited  to  epidemic  diseases.  Circulars 
on  tuberculosis  have  been  sent  to  physicians.  There  are  no  bovine 
laws. 

Utah. — No  board  of  health  or  any  organization  of  a  similar  kind 
whatsoever. 

Vermont. — Ko  answer,  but  I  learn  indirectly  that  this  State  kills 
tuberculous  cattle  and  recompenses  the  owner. 

Virginia. — Bovine  laws  are  enforced  by  the  board  of  control  of 
the  experimental  station  of  the  Virginia  Agricultural  and  Mechan- 
ical College  at  Blacksburg.  Circulars  on  the  restriction  of  con- 
sumption are  issued. 

West  Virginia. — No  bovine  laws.  Circulars  on  consumption  have 
been  issued. 

Wisconsin. — The  board  of  health  and  the  State  veterinarian  co- 
operate in  destroying  milch-cows  that  arc  tuberculous.  Circulars 
on  tuberculosis  in  man  are  issued. 

Wyoming. — No  State  board  of  health.  During  the  legislative 
sessions  of  1895  a  bill  was  introduced  to  create  one,  but  it  was  not 
passed.  Sanitary  regulations  are  left  to  the  cities,  some  of  which 
have  boards  appointed  by  ordinance. 

This  gives  us:  Fourteen  States  which  have  bovine  laws  and 
regulations  and  in  which  circulars  are  issued  for  public  instruction 
in  regard  to  tuberculosis  in  man,  viz. :  California,  Colorado,  Con- 
necticut, Iowa,  Maine,  Massachusetts,  Michigan,  New  Jersey,  New 
Hampshire,  New  York,  Pennsylvania,  Rhode  Island,  Virginia,  and 
Wisconsin ;  two  which  have  bovine  laws,  but  where  apparently 
nothing  is  done  to  stop  the  spread  of  tuberculosis  in  man,  viz. : 
Minnesota  and  South  Dakota  ;  one  which  has  bovine  laws  but  can- 
not enforce  them  for  lack  of  funds,  and  where  thus  far  the  board 
has  only  issued  circulars  on  the  prevention  of  tuberculosis  in  man 
and  beast,  viz.:  Tennessee;  two  (the  District  of  Columbia  and 
Oklahoma  Territory)  which  have  a  law  prohibiting  the  sale  of 
tuberculous  milk,  but  nothing  else  concerning  tuberculosis  in  man 


'*"■**"———- 


SANITARY    LAWS   TO    PREVENT    BOVINE   TUBERCULOSIS. 


73 


or  beast;  eight  which  issue  circulars  of  instruction  concerning 
tuberculosis  in  man,  but  where  nothing  is  done  in  regard  to  bovine 
tuberculosis,  viz. :  Delaware,  Indiana,  Kentucky,  Louisiana,  New 
Mexico  Territory,  Ohio,  Texas,  and  West  Virginia;  nine  where 
nothing  is  done  to  stop  the  spread  of  tuberculosis  in  either  man  or 
beast,  viz. :  Alabama,  Arkansas,  Illinois,  Kansas,  Maryland,  Mis- 
sissippi, North  Carolina,  North  Dakota,  and  South  Carolina ; 
seven  which  have  no  boards  of  health,  viz.:  Georgia,  Idaho, 
Montana,  Nebraska,  Oregon,  Utah,  and  Wyoming;  five  from 
which  I  have  received  no  answer,  viz. :  Florida,  Missouri,  Nevada, 
Vermont,  and  Washington. 

To  the  letters  addressed  to  the  health  officers  of  forty  of  our 
largest  cities  I  have  received  twenty-nine  answers.  In  one-third 
of  these  it  was  stated  that  nothing  at  ail  had  been  done  concerning 
the  prophylaxis  of  tuberculosis. 

This  state  of  affairs  speaks  for  itself  and  shows  that  as  a  nation 
we  have  a  most  limited  protection  from  tuberculosis  in  man  and 
beast. 

Let  us  consider  for  a  moment  the  injustice  done  to  States  with  ""J'' ^"".'■■s 

J  witli  good 

good  laws  in  regard  to  bovine  tuberculosis  by  those  which  have  no'j"^"^",^^"^ 
such  laws.  Where  interstate  traffic  exists  it  will  be  well-nigh  im  i,^,,^. 
possible  for  the  States  with  good  sanitary  laws  to  suppress  bovine 
tuberculosis  within  their  borders.  The  following  incident,  which  I 
have  from  a  reliable  source,  will  show  a  danger  and  injustice  to 
which  a  State  with  good  laws  is  no  doubt  frequently  exposed  :  A 
farmer  in  a  State  with  no  laws  to  suppress  bovine  tuberculosis 
enters  into  a  compact  with  a  friend  residing  in  a  neighboring  State 
where  the  government  kills  all  tuberculous  cattle  and  recompenses 
the  owner;  all  the  worthless  cattle  which  he  can  procure  are  driven 
across  the  line  to  the  friend.  At  the  next  visit  of  the  State  veteri- 
nary surgeon  these  cattle  are  found  tuberculous,  ordered  killed, 
and,  considering  their  real  value,  handsomely  paid  for.  The  farmer 
and  his  friend  divide  the  profit.  This  may  be  the  first  dire-t  loss  in 
money  to  the  State  with  good  laws,  but  how  mraiy  times  may  not 
these  diseased  cows,  secretly  imported,  be  the  cause  of  infecting 
whole  herds  of  valuable  cattle  ?  And  yet  the  citizens  of  the  State  with 
good  laws  in  regard  to  tuberculous  cattle,  though  imposed  upon, 
are  to  be  envied  ;  for  the  State  with  no  such  laws  is  an  unsafe  place 
to  live  in.  The  following  extract  from  the  "  lughth  Biennial  Re- 
port of  the  Iowa  State  Board  of  Health"  will  show  how  tiuc  this 


■  from 
those  with 


!i!! 


->  . 


f.WI 


74 


PULMONARY   TUBERCULOSIS. 


1    i 


Inspection 
of  cattle. 


is  :  "  Some  time  since  the  State  Veterinary  Surgeon  found  a  lot  of 
cattle  which  he  condenmed  as  tuberculous,  placing  them  under 
quarantine  and  expecting  in  a  day  or  two  to  slaughter  them.  Upon 
his  return  he  found  that  the  cattle  had  been  sold  to  be  shipped  out 
of  the  State  for  food."  The  seller  claimed  that  he  had  fully  made 
known  the  condition  of  the  cattle  to  the  buyer,  and  thus  the  law 
could  not  reach  him. 

To  effectually  combat  tuberculosis  in  cattle  and  other  domestic 
animals,  the  federal  government  is  alone  capable  to  do  the  worlc, 
and  should  have  in  this  respect  equal  juri.sdiction  over  all  the  States 
and  Territories.  Much  excellent  educational  work  has  already 
been  done  by  the  Bureau  of  Animal  Industry  under  the  direction 
of  its  distinguished  chief.  Dr.  D.  E.  Salmon.  However,  the  need 
of  concerted  action  must  certainly  be  felt  more  in  the  United  States 
than  in  other  countries. 

While  each  country  and  State  may  have  to  frame  its  bovine  laws 
and  regulations  in  accordance  with  the  demands  of  its  geographi- 
cal, climatic,  and  perhaps  also  its  political  situation,  there  are  some 
which  should  be  common  to  all.  From  a  careful  perusal  of  exten- 
sive literature  on  the  subject,  and  an  effort  to  make  myself 
acquainted  with  the  practical  workings  of  the  many  different  laws, 
regulations,  and  recommendations  concerning  the  restriction  of 
tuberculosis  in  cattle,  I  may  suggest  a  few  points  which  should 
form  part  of  the  rules  essential  to  the  prophylactic  work  instituted 
by  any  government  in  this  respect: 

1.  There  should  be  a  central  bureau,  from  whence  the  work  of 
the  sanitary  inspectors,  especially  educated  for  their  duties,  may  be 
directed. 

2.  Tliere  should  be  an  inspection  of  all  cattle  at  regular  inter- 
vals, besides,  of  course,  always  upon  the  demand  of  the  owner. 

Regarding  the  manner  in  which  the  inspection  should  be  carried 
on,  I  have  not  found  in  all  the  literature  anything  more  practical 
and  more  thorough  than  the  directions  given  by  Professor  Leonard 
Pearson,  the  distinguished  State  Veterinarian  of  the  State  of  Penn- 
sylvania, and  I  take  great  pleasure  in  reproducing  them  ///  cxtcuso. 


"  DIRECTIONS  FOR  INSPECTING  HERDS  FOR  TUBERCULOSIS. 

"  Inspection  should  he  cai.i.d  on  wliile  tlic  Iierd  is  stahloch  If  it  is 
necessary  to  stal)le  animals  tmdcr  luuisual  conditions  ov  among  imiisnal 
surroundings  tliat  make  them  uneasy  and  excited,   the  tuberculine  test 


SANITARY    LAWS   TO    PREVENT    liOVINE   TUBERCULOSIS. 


75 


should  he  postponed  until  tlie  cattle  have  become  accustomed  to  the 
conditions  they  are  subjected  to,  and  then  begin  with  a  careful  physical 
examination  of  each  animal.  This  is  essential,  because  in  some  severe 
cases  of  tuberculosis  no  reaction  follows  the  injection  of  tuherculine,  but 
experience  has  shown  that  these  cases  can  be  discovered  l)y  physical 
examination.  This  examination  should  be  complete  and  include  a  care- 
ful examination  of  the  udder,  and  of  the  superficial  lymphatic  glands 
and  anscidtation  of  the  lungs. 

"  Each  animal  should  be  numbered  or  described  in  such  a  way  that  it 
can  be  recognized  without  difficulty.  It  is  well  to  number  the  stalls  with 
chalk  and  transfer  these  numbers  to  the  temi)erature  sheet,  so  that  the 
temperature  of  each  animal  can  be  recorded  in  itsapprojjriate  place  with- 
out danger  of  confusion.  The  following  procedure  has  been  used  exten- 
sively and  has  given  excellent  results: 

"  (a)  Take  the  temperature  of  each  animal  to  be  tested  at  least  twice, 
at  intervals  of  three  hours,  l)efore  tuberculine  is  injected. 

"  (/>)  Inject  the  tuberculine  i  in  the  evening,  ])referably  between  the 
hours  of  6  and  9.  The  injection  should  be  made  with  a  carefully  steril- 
ized hypodermic  syringe.  The  most  convenient  point  for  injection  is 
back  of  the  left  .scapula. 

"Prior  to  the  injection  the  skin  should  be  washed  carefully  with  a 
five  percent,  solution  of  creoline  or  other  antiseptic. 

"  (c)  The  temperature  .should  be  taken  nine  hours  after  the  injection, 
and  temperature  measurements  repeated  at  regular  intervals  of  two  or 
three  hours  until  the  sixteenth  hour  after  the  injection. 

"  ((/)  When  there  is  no  elevation  of  temperature  at  this  time  (sixteen 
hours  after  injection)  the  examination  may  be  discontinued  ;  but  if  the 
temi)erature  shows  an  upward  tendency,  measurements  must  be  continued 
until  a  distinct  reaction  is  recognized,  or  until  the  temperature  begins  to 
fall. 

"  (e)  If  a  reaction  is  detected  prior  to  the  sixteenth  hour,  the  meas- 
urements of  temperature  should  be  continued  until  the  e.v[)iration  of  this 
period. 

"  (/)  '{"he  thermometers  used  for  this  work  should  be  accurate,  and 
if  several  are  used  they  should  be  compared  before  the  examination  is 
commenced. 

"  (.i,"-)  If  there  is  an  imusual  change  of  tem]ierature  of  the  stable,  or  a 
sudden  change  of  weather,  this  fact  should  l)e  recorded  on  the  report 
blank. 

"(//)  If  a  cow  is  in  a  febrile  condition  when  the  initial  temperatures 
are  taken,  tuberculine  should  not  be  used  on  her,  because  in  this  case  the 
temperature  curve  is  irregular  and  the  result  of  the  test  imcertain. 

"  (■/)  Cows  should  not  be  tested  within  a  few  days  before  or  after 
calving,  for  experience  has  shown  that  the  result  at  these  times  may  be 
misleading. 

''  (  /  )  The  tuberculine  test  is  not  reconunended  for  calves  under  three 
months  old. 


; 


ii«t- 


'  Average  dose  ;  0.25  c.c.     In  diluting  for  an  injection  a  10  per  cent,  solution  of  tiil)er- 
culine  is  made  l)y  adding  9  parts  of  a  I  per  cent,  solution  of  ac.  carliol. 


I?  I 


76 


PULMONARV    TUIiKKCULOSlS. 


ijtfi     ' 


"  (/:)  In  old,  emaciated  animals  and  in  rotests  use  twice  the  iisnal 
dose  of  tuborciiline. 

"In  reporting  upon  the  examination  of  thv.  herd,  the  large  temjiera- 
tiire  sheets  should  he  fillet!  out  and  returned,  togetiier  with  a  more  de- 
tailed record  for  each  animal  that  i)roves  to  be  tuberculous.  This  de- 
tailed report  should  be  made  out  on  the  individual  report-blanks  provided 
for  this  pur|iose. 

"Condemned  cattle  must  be  removed  from  the  herd  and  kejit  away 
from  those  that  are  healthy. 

"  In  special  cases  inspectors  may  be  directed  to  destroy  and  make 
|)ost-mortem  examinations  upon  the  condemned  animals  as  soon  as  they 
are  recognized,  but  this  must  only  be  done  when  directions  to  this  effect 
are  given  in  the  original  letter  of  advice. 

"In  making  post-mortems  the  carcasses  should  be  thoroughly  in- 
spected, and  all  of  the  organs  mentioned  on  the  blank  for  reporting  this 
work  should  be  examined." 


i  J, 


3.  There  should  be  a  thorough  destruction  of  all  tuberculous 
meat,  etc.,  and  a  most  thorough  disinfection  and  cleaning  of  the 
stables  and  all  utensils  which  may  have  come  in  contact  with  the 
tuberculous  animals.  The  owner  of  the  cattle  should  be  instructed 
in  regard  to  the  sanitary  arrangements  to  prevent,  as  far  as  pos- 
sible, a  new  outbreak  of  the  disease.  He  should  be  especially 
instructed  as  to  the  precaution  to  be  taken  before  introducing  new 
animals  into  the  herd. 

4.  There  should  be  a  just  compensatioii  for  his  loss  according 
to  the  actual  value  and  condition  of  the  animals  at  the  time  of 
appraisement. 

5.  There  should  be  a  careful  examination  of  all  imported  cattle 
and  the  strict  exclusion  of  all  tuberculous  animals. 

6.  While  several  authors  caution  against  the  employment  of  a 
consumptive  to  help  about  cattle  or  in  the  dairy,  I  have  failed  to 
discover  anything  in  the  literature  on  the  subject  calling  attention 
to  the  fact  that  the  presence  of  any  disease  such  as  diarrhcea  in 
children  or  adults,  persistent  cough,  bronchitis,  pleurisy,  local 
badly  healing  sores  in  any  one  on  or  about  the  premises,  might 
lead  to  the  detection  of  bovine  tuberculosis  among  the  cattle  of 
which  they  had  charge,  or  of  which  they  received  milk.  I  would 
tluis  make  it  compulsory  to  notify  the  nearest  sanitary  authority 
of  the  occurrence  of  any  of  the  above-named  diseases,  in  addition 
to  typhoid  fever,  scarlatina,  diphtheria,  etc.,  on  the  premises  in  the 
vicinity  of  where  milch-cows  are  kept. 

7.  A  thorough  supervision  of  all  the  slaughter-houses,  milk- 


SANITARY   LAWS   TO    PKKVKNT   BOVINE  TUBERCULOSIS. 


17 


depots,  butcher-shops,  and  jiIl  tlie  retail  milk-stores  is,  of  course, 
also  one  of  the  vital  points  to  he  considered  in  our  strife  against 
tuberculosis  in  man  or  beast. 

Of  the  many  interesting  letters  which  I  received  in  reply  to  my 
inquiries  there  is  one  from  Indiana  which  gives,  concerning  the 
question  of  how  to  solve  the  problem  of  combating  bovine  tuber- 
culosis, such  a  unique  and  practical  method,  without  having  even 
resource  to  the  law,  that  I  tliink  it  my  duty  to  reproduce  here  this 
letter  in  cxtenso.  I  am  sure  my  distinguished  friend,  Dr.  Hurty, 
will  pardon  nie  for  doing  so,  since  the  example  set  by  the  wise 
City  board  of  Indianapolis  can  only  be  productive  of  much  good, 
and  is  certainly  worthy  of  emulation : 

"  Oii'iCK  OF  State  Board  ok  Health  oe  Indiana, 
"Indianapolis,  February  7,  1898. 
"  Dr.  S.  a.  Knoi'K,  New  York  : 

^^  Dear  Doctor:  In  reply  to  your  favor  of  February  3d.  The  snl)ject 
in  wliich  you  arc  so  deeply  interested  is  being  agitated  in  this  State,  but 
at  the  present  time  there  are  no  special  hospitals,  either  public  or  private, 
for  coiisuinijtives.  In  this  city,  Indianapolis,  a  good  work  toward  the 
suppression  of  tuberculosis  is  being  done  without  intervention  of  law. 
The  City  15oard  of  Health  induced  one  of  the  iirominent  dairymen  to 
write  a  letter,  rcijuesting  tliat  his  herd  be  tested  witii  tuberctiline,  and 
also  that  a  sanitary  survey  be  made  of  his  dairy  and  suggestions  be  made 
for  sanitary  inipvovements,  lie  pronusing  to  destroy  all  cattle  wiiieh  re- 
acted to  the  tuherculihe  test,  and  to  make  all  sanitary  improvciiients 
suggested.  For  this  he  was  to  receive  a  certificate  from  the  Board  of 
Healtli,  simjily  stating  the  facts  of  the  case.  This,  you  see,  was  a  true 
commercial  metiioti.  'I'he  work  was  done,  as  above  indicated,  and  im- 
nietliate'y  the  popular  demand  arose  for  tlie  milk  suiiplied  from  tuber- 
culine-ttsted  animals,  livery  dairy  supjiiying  milk  to  tiiis  city  has  now 
been  tested  and  sanitary  surveys  made,  as  above.  About  six  jjer  cent,  of 
the  duiry  cattle  have  been  killed,  and  in  every  instance  it  was  discovered 
that  tlie  tubercuiine  test  was  accurate  and  al)soiute.  This  method  seems 
better  than  the  legal  method.  Some  of  the  i)Oor  dairymen  have  rebelled 
somewhat  against  the  loss  of  their  animals,  but  the  answer  given  them  is 
final  and  cor.iplete — viz.,  that  no  matter  how  poor  they  are,  or  what 
financial  injury  may  be  brought  to  them,  still  they  have  no  right  to  fur- 
nish milk  which  will  probably  produce  disease  and  death.  I  believe, 
however,  it  would  not  be  bad  policy  for  the  State  to  pay.  say,  one-half 
the  value  of  the  cattle  slaughtered  on  account  of  tuberculosis.  This 
would  be  a  mere  matter  of  jjuIjUc  policy  to  aid  in  a  consummation  which 
is  devoutly  to  be  wished. 

"  Communications  from  citizens  and  physicians  have  appeared  in  our 
local  papers  advocating  public  homes  for  consumptives.      We  think, 


Solving  tlie 
tuberculous 
milk  prob- 
lem with- 
out tlie  aid 
of  the  law. 


■m 


;>  W^ 


7« 


PULMONARY    TUnEKCULOSIS. 


therefore,  it  will  not  be  long  before  Indiana  will  be  able  to  report  prog- 
ress in  this  direction. 

"Thanking  you,  I  am  veiy  truly  yours, 

'•J.  N.  HuKTV,  Seife/(irv." 

Tuberculosis  in  hogs  is  not  infrequent,  but  the  cause  of  the  dis- 
ease can  almost  always  be  traced  to  the  infection  from  tuberculous 
bovine  products.  I  quote  from  Pifiard's  article  in  the  "  New  York 
Medical  Record"  of  April  3,  1897': 

"  Tlie  rej)ort  of  the  C"o])enhagen  Experiment  Station  ^  's  that  at  a 
Danish  creamery,  where  the  centrifuge  slime  was  fed  to  swiiit.  all  of  these 
l)roved  tuberculous,  and  warns  against  the  use  of  slime  for  this  ])urpose 
witliout  its  being  previously  boiled  or  heated  toward  tiie  temperature  of 
boiling  water.  The  prevalence  of  tuberculosis  among  swine  in  certain 
parts  of  (lermany  lias  been  attributed  to  this  system  of  feeding. " 

Many  other  examples  pointing  in  the  .same  direction  might  be 
quoted.  The  rare  instances  of  tuberculosis  in  horses,  goats,  dogs, 
etc.,  can  doubtlessly  always  be  traced  to  an  infection  by  tubercu- 
lous products  from  either  man  or  cattle. 


'  Piffard,  "  On  the  Tuberculosis  Question." 


!     1 


w 


chapti;r  VII. 


PREVENTIVE    TREATMENT. 


In  the  previous  cliapters  we  have  spoken  of  the  measures 
wliich  mi^ht  be  instituted  to  prevent  tlie  germ  of  tuberculosis  from 
enterint^  tlie  liunian  system  throu|^h  cither  the  n-spiratory  or  the 
digestive  tract,  or  through  inoculation,  l^ut  even  with  the  most 
severe  laws  and  regulations  the  bacillus  tuberculosis  will  not  van- 
ish completely.  For  a  long  time  to  come  there  will  be  only  too 
many  chances  to  contract  tuberculosis  through  the  carelessness  of 
consumptives,  or  the  unscrupulousness  of  meat-dealers,  farmers,  or 
dairymen,  or  through  the  bacilli  that,  even  with  the  best  intentions 
on  the  part  of  the  sanitary  authorities  and  their  co-workers,  are 
likely  to  escape  detection.  What,  then,  can  we  do  to  protect  our 
system  against  the  invasion  of  this  deadly  micro-organism  ? 

(^ur  bacterio-therapeutists  have  thus  far  failed  to  give  us  any 
remedy  which  we  might  safely  inject  as  an  immunizing  agent  to 
prevent  the  development  of  tuberculosis.  I  should  rejoice  if  such 
a  boon  would  still  be  in  store  for  mankind.  However,  we  need 
not  despair  in  the  meantime.  If  the  teachings  of  modern  phthisio- 
therapeutists  are  followed,  even  the  cliild  of  tuberculous  parent.s 
may  become  a  strong,  health)'  man  or  woman,  and  the  accidental 
inhalation  or  ingestion  of  the  tubercle  bacilli  will  not  suffice  to 
make  a  consumptive  of  him  or  her.  Vor,  as  we  have  already 
stated,  it  is  the  weak  and  enfeebled  organism  which  becomes  the 
easy  prey  of  the  bacillus  tuberculosis.  One  in  f;iir  health,  living  a 
regular  and  hygienic  life,  has  little  to  fear.  The  bactericidal 
quality  of  his  nasal  mucous  membrane  will  protect  him  from  harm 
through  the  inhalation  of  the  bacilli,  while  the  good  phagocitic 
action  of  liis  blood  will  protect  him  from  harm  through  the  inges- 
tion of  tuberculous  meat  or  milk,  or  from  the  i)acilli  which  he  may 
have  taken  in  with  the  dust  in  the  air  while  speaking  or  breathing 
through  the  mouth. 

A  predisposition  to  pulmonary  tuberculosis  may  be  inherited  or 
acquired,  but  in  either  case  the  means  to  overcome  this  peculiar 

79 


'I 


:-s! 


m 


8o 


I'ULMONAKY    TUIIEKCULOSIS. 


!  1    ■ 


f    t 


if 


Descri|ilioii 
of  an  iiidi- 
vidiml  |iiv- 
ilisposeil  to 
CDiisiinip- 
tioii. 


sus^cptiljility  are  the  same.  Let  us  exainine,  for  a  moment,  an 
indivicliial  predisposed  to  consumption,  ami  we  will  be  better  able 
to  understand  the  reasons  for  the  therapeutic  measures  which  I  shall 
describe.  If  it  be  a  child  he  will  be  either  undersized  or  jiresent 
an  almost  abnormal  hei^dit  for  his  age,  with  a  narrow  chest,  lie 
will  be  a  bad  cater,  irritable,  nervous,  aniumic,  with  irregular  diges- 
tive functions,  at  times  constipated,  at  times  suffering  from  diar- 
rhoea, prone  to  all  the  diseases  of  childhood,  and  still  mentally 
rarely  behind  his  more  robust  companions.  He  is  averse  to  out- 
door play,  and,  owing  to  his  delicate  constitution,  he  is  allowed  to 
have  his  way,  and  his  character  is  often  spoiled. 

The  adult  candidate  for  pulmonary  tuberculosis  differs  from  his 
younger  brother  but  little  ;  the  physique  is  the  same  ;  the  peculiar 
condition  of  mind  is  more  pronounced  ;  while  sanguine  at  times, 
anxieties,  disappointments,  especially  unfortunate  love  affairs,  and 
similar  sorrows,  often  suffice  to  bring  about  a  rapid  development 
of  the  disease.  In  sorrow  one  eats  but  little,  the  arterial  pressure 
is  low,  the  muscular  weakness  and  depressed  nervous  state  make 
the  act  of  breathing  incomplete.  The  beneficial  influence  of 
natural  and  full  breathing  does  not  e.xist  any  more  ;  the  heart  is 
called  on  to  iXo  more  work  and  a  perpetual  palpitation  ensues. 
The  circulatory  disturbances  in  the  lungs  impair  the  nutrition  of 
this  organ,  and  thus  the  field  for  the  invasion  of  the  bacillus  of 
tuberculosis  is  prepared. 

The  decreased  power  of  resistance  makes  the  anremic  individual, 
in  addition,  especialljr  prone  to  acute  inflammations  of  either  the 
mucous  or  serous  membranes,  and  catarrhal  conditions  of  the  upper 
respiratory  organs  become  alarmingly  frequent  and  inclined  to 
descend  into  the  deeper  air-passages.  And  why  do  these  people 
take  cold  so  easily  and  frequently?  Because  their  vasomotor  sys- 
tem is  impaired,  and  the  slightest  change  of  temperature  or  insig- 
nificant e.^ijosure  of  some  part  of  the  body  usually  covered  suffices 
to  hinder  the  peripheral  circulation  to  the  extent  of  producing  con- 
gestions and  to  impair  the  process  of  eliminating  used-up  sub- 
stances, whose  toxicity  increases  with  the  length  of  time  they  are 
retained. 

It  seems  evident,  then,  that  the  insufficient  air-supply  to  the 
respiratory  organs  and  the  increased  susceptibility  to  the  slightest 
change  of  temperature  are  the  principal  factors  in  the  production 
of  consumptive  individuals.     Therefore  to  prevent  or  improve  the 


iijliOT'illil'liriviVij 


T 


FKEVENTIVK   TKKATMKNT. 


8i 


cniulition  caused  by  an  insufficient  air-supply  we  must  resort  to 
acrotlierapeutics,  and  to  arouse  tlie  vasomotor  system  to  a  more 
ener^'etic  action  we  have  in  liycirotlicrai)eutics  not  the  only,  but, 
considering  its  salutary  secondary  effects,  the  most  valuable  thera- 
peutic ajjent. 

To  prevent  pulmonary  tuberculosis  we  must  begin  with  treating 
the  child  /'//  tt/t/v,  continue  in  the  lying-in  room,  nursery,  antl 
school-room,  and  teach  the  young  man  or  woman  to  keep  the 
treatment  up  throughout  life.  A  woman  who  is  to  give  birth  to 
a  child  should  abandon  the  corset  and  tight  clothing  in  time  to 
allow  a  continued,  free  abdominal  and  thoracic  respiration.  Wiser 
yet  if  she  never  liad  been  addicted  to  the  habit  of  tight-lacing,  for 
the  experiments  of  Kellogg  '  and  Mays  have  demonstrated  that  the 
so-called  female  or  costal  type  of  respiration  wiiich  prevails  among 
civilized  women  is  the  result  of  their  restricting  and  unhygienic 
mode  of  dress,  and  is  not  due  to  the  influence  of  gestation  or  to  a 
natural  difference  in  the  anatomo-physiological  growth  of  man  or 
woman. 

For  the  mother  to  live  as  much  as  possible  in  pure,  fresh  air,  to 
take  frequent  breathing  exercises,  to  avoid  crowded  assemblie.-; 
where  the  air  is  vitiated,  ami  live,  in  short,  as  hygienic  a  life  as  cir- 
cumstances will  permit,  will  have  a  most  salutary  effect  on  the 
child's  future  health.  The  new-born  child  is  in  need  of  pure,  ''resh 
air  as  much  as  the  mother;  and  the  lying-in  room  and  the  nursery 
shoultl  always  be  well  ventilated.  When  the  child,  in  time,  is  taken 
for  an  airing,  the  thick,  almost  impermeable  veil  should  be  aban- 
doned. These  veils,  often  tightened  around  the  little  face,  press 
against  the  nose  and  make  it  difficult  for  the  child  to  breathe 
naturally,  and  the  mother  wonders  why  the  baby  got  into  the  habit 
of  breathing  through  the  mouth. 

Frequently,  also,  mouth-breathing  in  children,  and  sometimes  in 
atlults,  must  be  attributed  to  adenoid  vegetation  in  the  retro- 
pharynx,  or  to  enlarged  tonsils.  These  as  well  as  all  other  causes 
of  obstruction  to  a  free,  natural  respiration,  such  as  deviated  septum, 
spores,  enlarged  turbinated  bones,  hypertrophied  mucous  mem- 
brane, polypus,  etc.,  must  be  removed  if  we  desire  to  protect  the 
child  or  adult  from  chronic  nasal,  pharyngeal,  and  laryngeal  catarrhs, 
so  often  the  forerunners  of  pulmonary  diseases. 

'  Kellogg,  "  Experimental    Researches   Re?.|)ecting  the  Kehitioii  of  Dress  to  Pelvic 
Diseases  of  Women,"  "  Transactions  of  the  Micliigaii  Stale  Med.  Society." 
6 


l'ri)|>hy- 
lactic  ircal- 
inciit 
sIkiuIcI 

tlu'  child 
///  u/t'yu. 


Moiitli- 
brcatliiiiK. 


t1  ',i!         («' 


m 


i   .t  ' 

(    111 


PULMONARY   TUBERCULOSIS. 


I  mi 


!15J: 


i*,i 


,174 

H 


KespiraUiry 
exercises. 


Only  after  the  removal  of  all  possible  causes  of  obstructions  in 
the  upper  air-passages  is  a  natural  physiological  respiratory  func- 
tion possible,  and  only  under  such  conditions  can  we  hope  for  real 
benefit  from  breathing  exercises. 

I  consider  the  air-bath  and  sun-bath  for  children  at  the  earlier 
age  most  beneficial.  Let  the  little  ones  toddle  around  naked  every 
day  for  a  short  time ;  in  cold  weather  in  well-warmed  rooms,  and 
in  summer  in  the  room  bathed  by  the  rays  of  the  sun.  They  will 
become  less  susceptible  to  colds  than  if  always  carefully  bundled 

In  localities  where  it  is  impossible  to  prevent  the  constant  inha- 
lation of  coal-dust  or  ether  irritating  substances,  a  regular  nasal 
toilet  with  a  milH  antiseptic  solution,  or,  perhaps,  best  of  all,  plain 
tepid  but  previously  boiled  water,  should  be  instituted  for  children 
until  they  are  old  enough  to  blow  their  noses  properly. 

As  soon  as  the  age  and  intelligence  of  the  child  will  permit, 
breathing  exercises  should  be  taught  to  him.  He  should  learn  to 
love  them,  as  the  average  child  likes  general  gymnastics.  The  fol- 
lowing is  a  description  of  the  exercises  I  recommend  to  all  children 
and  .dults  who  breathe  faultily,  to  the  an;tmic,  the  predisposed, 
and  to  the  chronic  tuberculous  patient  who  is  able  to  be  about  and 
where  a  modification  is  not  indicated.  These  are  also  a  par*-  of 
the  gymnastic  exercises  I  should  like  to  see  incorporated  in  the 
curriculum  of  all  schools,  and  not  only  in  the  selected  few.  I  have 
prescribed  them  for  years  with  very  satisfactory  results,  and  I  can 
recommend  them  as  practical,  efficacious,  and  easily  learned. 

Presuming'that  the  upper  air-passages  are  in  a  normal  condition, 
the  patient  is  taught  to  stand  properly — that  is  to  say,  straight,  chest 
out,  and  head  erect — and  to  breathe  always  through  the  nose.  He 
takes  a  deep  inspiration  slowly,  beginning  with  the  abdominal 
muscles  and  then  expanding  the  chest  to  its  fullest  capacity.  Dur- 
ing this  inspiration  he  raises  his  arms  from  his  sides  to  a  horizontal 
position  (Fig.  13).  He  holds  the  breath  for  a  moment,  and  then 
lowers  the  arms  during  the  act  of  expiration,  which  should  be 
somewhat  more  rapid. 

The  second  exercise  is  like  the  first,  except  that  the  upward 
movement  of  the  arms  is  continued  until  the  hands  meet  over  the 
head. 

In  the  third  exercise  the  patient  stretches  his  arms  out  as  in  the 
position  of  swimming,  the  dorsal  sui.aces  of  the  hands  touching 


PREVENTIVE   TREATMENT. 


83 


each  other.  During  the  inspiration  the  arms  are  moved  outward 
and  finally  meet  behind  the  back.  They  are  brought  forward  again 
during  the  expiration.  This  exercise  can  be  gr.atly  facilitated  and 
made  more  effective  by  the  patient  rising  on  his  toes  during  the  act 
of  inspiration,  and  descending  during  the  act  of  expiration.  Each 
respiratory  act  should  be  followed  immediately  by  a  secondary secomiary 
forced  expiratory  effort.     This  is  for  the  purpose  of  expelling  aspiratory 


KiG.  13.— First  asu  Sixond  Rlsimkaiorv  ExKRCisiiS. 

much  of  the  supplemental  air  as  possible,  and  may  be  effectually 
aided  by  supinating  the  arms  and  pressing  the  thorax  with  them. 

Considering  that  the  amount  of  tidal  air — that  is  to  say,  the  vol- 
ume which  is  inspired  and  expired  in  quiet  respiration — is  only  500 
c.c,  the  complemental  air — the  volume  which  can  be  inspired  after 
an  ordinary  respiration — 1500  c.c,  and  the  si'pplemental  or  reserve 
air — the  amount  which  can  be  forcibly  expelled  after  an  ordinary 
respiration — amounts  to  1240  to   1800  c.c,  one  can  readily  see  the 


!i 


84 


PULMONAKY  TUBERCULOSIS. 


value  of  respiratory  exercises,  and  also  the  utility  of  this  second 
expiratory  effort. 
Usual  scat        The  fact  that  in  the  majority  of  cases  the  tuberculous  process 

of  ))ninaiy  ^  _  ^  ^ 

lesion.  begins  at  the  apices  has  been  t.xp'.c-ined  by  the  supposed  bad  inspi- 
ratory function  of  this  part  of  the  lungs.  Now,  I  agree  in  this 
respect  with  Hanau,'  and  consider  the  almost  universally  adopted 
statement  of  the  deficient  inspiratory  function  of  the  apices  erro- 


4/j. 


/  "- 


i  /-■-•■A^^- 


\^ 


Fig.  14.— Tiimn  Ki;.si'Ikatukv  Kxkrcise. 


Fig,  15.— t.\K.''i' ;;  for  Patients  in  the 
H.Mirr  OK  Stooping. 


neous.  On  the  contrary,  these  portions  of  the  lungs  inspire  excel- 
lently well,  almost  too  well,  for  dust  and  all  sorts  of  micro-organ- 
isms enter  there  mo.st  easily  and  are  found  in  large  quantities  in 
careful  post-mortem  examinations.  What  is  faulty  is  the  expi- 
ratory function   of  the    apices.     A  thorough  expiration   followed 


'  Ilaiiaii,   A.,   Ziiricli,    "  Reitnlge  ziir  Pathologic  dor  Luiigenkmnkliciten,"  "  Ze it- 
schrift  fiir  Ulin.  Muilicin,"  xii,  1S87. 


PREVENTIVK    TREATMEM'. 


85 


by  a  forced  expiratory  effort,  as  described  above,  is,  to  my  mind, 
the  only  possible  way  to  improve  tiiis  defect  and  prevent  stagnation 
and  conj^estion,  wliich,  as  is  well  known,  torni  excellent  media  for 
the  development  of  bacilli. 

To  consumptive!-',  those  predisposed  to  tuberculosis,  and  to 
children  who  have  the  habit  of  stooping,  I  teach  an  additional 
exercise,  as  follows  (Fig.  15):  The  patient  makes  iiis  best  effort  to 
stand  straight;  he  places  his  hands  on  his  hips  with  the  tluimbs 
toward  the  front  and  then  bends  slowly  backward  as  far  as  lie  can 
during  the  act  of  inspiration.  He  remains  in  this  jxjsition  a  few 
seconds  while  holding  the  breatii,  and  rises  again,  somewliat  more 
rapidly,  during  the  expiration. 

When  the  patient  is  out  walking  it  will,  ot  course,  not  always  be 
convenient  nor  possible  to  do  these  exercises  with  the  movement 
of  the  arms.  The  patient  should,  under  such  conditions,  content 
himself  with  raising  his  shoulders  and  making  a  rotatory  moxe- 
ment  backward  during  the  act  of  inspiration,  holding  tlie  breath 
for  a  moment  and  then  exhaling  during  a  rotatory  movement  for- 
ward, assuming  again  the  normal  position.  The  second  respiratory 
effort  can  follow  this  exercise  also  without  attracting  any  attention. 

For  all  classes  of  patients,  candidates  for  consumption  and  bad 
breathers  in  general,  the  rules  hold  good  never  to  take  their  breath- 
ing exercises  when  tired  or  immediately  after  a  heavy  meal,  never 
when  uncomfortably  or  tightly  dressed,  never  to  continue  them 
to  the  extent  of  becoming  tired,  never  to  take  them  in  a  bad  at- 
mosphere, and  not  to  take  them  at  their  caprice,  but  according  to 
the  directions  of  the  physician. 

One  exercise  should  be  taught  at  a  time,  and  only  after  it  .s 
thoroughly  mastered  should  the  physician  proceed  to  teach  the 
next  one.  I  have  described  them  in  the  order  of  their  difficulty. 
The  first,  a  simple  raising  of  the  arms  to  the  horizontal  line  during 
the  act  of  inspiration,  requires  relatively  little  effort.  The  second 
one,  in  which  the  arms  describe  a  circle  by  being  raised  out- 
stretched until  thej'  meet  above  the  head,  requires  a  more  prolonged 
inspiration  and  necessarily  an  increased  muscular  effort.  The  third, 
the  swimming  exercise,  in  which  the  hands  should  meet  behind  the 
back,  is  the  most  tlifficult.  The  necessary  length  of  time  between 
learning  the  exercises  will  dejjend  upon  the  aptitude,  the  expansive 
power,  and  the  general  condition  of  the  patient.  Some  patients 
can  be  taught  all  these  exercises  within  nine  or  ten  days,  while  with 


ml 


Hdi' 


86 


PULMONARY   TUBERCULOSIS. 


11  « 


Rreathing 
exereisfs  at 
school. 


others  months  often  must  intervene  before  the  next  exercise  can 
be  commenced. 

The  breathing  exercises  at  school  should  be  under  the  direction 
of  the  school  physician  or  teacher  of  physical  culture.  In  suu'.mer 
they  should  be  taken  out-of-doors,  and  on  rainy,  windy,  or  too  cold 
days  in  the  school-room,  which  should  be  a  model  of  ventilation. 
To  teach  the  children  how  to  breathe,  sit,  stand,  and  walk  properly, 
should  be  a  part  of  the  every-day  curriculum.  Every  school 
should  have  its  large  playground  or  roof-garden,  where,  weather 
and  season  permitting,  the  classes  should  alternately  receive  their 
instruction.  In  rural  communities,  during  iiie  warmer  season,  in- 
struction in-doors  should  be  the  exception,  not  the  rule.  Singing 
and  recitation  especially  should  be  encouraged  out-of-doors.  I 
have  found  that  singing  in  pure  air  is  an  admirable  and  most  useful 
adjuvant  in  acrotherapeutics.  Barth,'  of  Koslin,  who  has  made  a 
careful  study  of  the  effects  of  singing  on  the  action  of  the  lungs 
and  heart,  on  diseases  of  the  heart,  on  the  pulmonary  circulation, 
on  the  blood,  the  vocal  apparatus,  the  upper  air-passages,  the  ear, 
the  general  health,  the  development  of  the  chest,  on  metabolism, 
and  on  the  activity  of  the  digestive  organs,  has  come  to  the  con- 
clusion that  singing  is  one  of  the  exercises  most  conducive  to 
health.  Considering  the  fact  that  it  can  be  practised  anywhere 
(when  the  air  is  pure)  or  at  any  time,  without  apparatus,  it  should 
be  much  more  cultivated  than  it  actually  is.  The  German  military 
authorities,  which  have  the  reputation  for  instituting  all  exercises 
which  tend  to  invigorate  the  soldiers,  have  of  late  years  encour- 
aged singing  during  marches  of  all  the  troops. 

Before  closing  with  the  subject  of  school  hygiene,  I  can  not  help 
repeating  here  the  very  impressive  words  of  Dr.  W.  W.  Hitchcock,- 
in  his  article  on  the  gymnasium  as  a  sanitary  measure.  Referring 
to  the  frequent  lack  of  the  development  of  the  thorax,  particularly 
noticeable  in  those  predisposed  to  pulmonary  diseases,  he  said  : 
"  There  is  no  doubt  that  if  as  much  care  were  bestowed  on  our 
young  in  seeing  that  this  particular  part  was  developed  with  that 
care  tiiat  the  brain  receives,  tuberculosis;  would  almost  disappear." 

Finally,  it  can  not  be  impressed  too  strongly  on  the  minds  of 


I 


» 


'  "Aiuliiv  fiir  L.iryngologje,"  5.      "Deutsche  Mtilicinal  Zeitung,"  Nov.  15,  1S97, 

2  Hitclu'dck,   W.  W.,"Tlie  (Jyiiiiiasium   from  tlie  Standpoint  of  the   Suiiitiiriiiii," 
"I'lansait,  of  the  I'durlli  Calif.  Saiiit.  (  onveiition,"  1896 


PREVENTIVE   TREATMENT. 


87 


I 


consumptives,  and  those  predisposed  to  the  disease,  tliat  they 
should  always  seek  environments  where  the  air  is  as  pure  as  pos- 
sible.    Lord  Beaconsfield's  celebrated  words,  "The  atmosphere  ini^rti 

'■  Beacon  s- 

which  we  live  has  more  to  do  with  human  hapiiiness  than  all  thei'ii''*"' 

'  '  piMo  all. 

accidents  of  fortune  and  all  the  acts  of  (government,"  have,  I  think, 
a  special  meaning  for  this  class  of  sufferers. 

Hydrotherapeutics,  as  a  measure  to  prevent  pulmonary  tuber-  "y'"™- 
culosis,  tends  to  develop  to  a  more  \i<rorous  action  the  vasomotor 'i^si<>  , 

'  ^  striMinlluii 

system,  and  should  also  be  instituted  at  an  early  a<je.  A  child  a"  i""''^' 
few  months  old  can  support  with  impunity  a  rapid  sponging^  Qffimiividuai. 
with  cold  water,  followed  by  a  relatively  vigorous  friction  with  a 
soft  Turkish  towel  after  its  warm  bath.  As  the  child  grows  older 
he  should  not  only  be  taught  this  use  of  cold  water  after  his  semi- 
weekly  or  weekly  bath,  but  he  should  wash  at  least  the  face,  neck, 
and  chest  every  morning  with  cold  water.  Better  y(;t  if  he  can 
accustom  himself  early  to  a  daily  cold  dcjche.  The  utility  of  all- 
the-ycar-round  swimming  baths,  where  old  and  young  of  all  classes 
can,  gratuitously  or  for  a  moderate  price,  enjoy  the  salutary  effects 
on  body  and  mind  of  a  good  sivim,  is  too  well  known  to  need 
repeeiting. 

For  an.nemic  individuals  who,  as  I  stated  above,  are,  in  the 
majority  of  cases,  candidates  for  consumption,  a  graduated  course 
of  hydrotherapeutics  seems  to  act  almost  as  a  specific.  That  there 
is  never  an\  danger  from  a  judiciously  applied  affusion  or  douche 
has  been  tlemonstrated  by  years  of  pVactice.  And  why  should 
there  be  ?  All  that  is  necessary  is  to  insure  the  proper  reaction  and 
an  education  of  the  skin  and  nervous  system  before  the  classical 
douche  is  employed.  The  surest  sign  of  a  proper  reaction  is  the 
appearance  of  a  red  hue  of  the  skin  where  the  water  had  been 
applied.  No  exception  should  be  made,  whether  the  patient  is  simply 
predisposed,  an  an;emic,  or  a  full}-  developed  consumptive;  it  is 
always  best  to  begin  with  a  dry  massage  for  several  days,  and  if  the 
skin  is  particularly  dry  I  prescribe,  in  addition,  inunction  with  some 
fatty  .'^ubstance,  preferably  cod-!ivcr  oil.  Ne.xt,  for  about  the  same 
period  of  time,  comes  the  friction  with  pure  alcohol ;  then  with  half 
alcohol  and  water  ;  finally,  the  friction  with  water  alone.  Then 
comes  the  cold  sponge-bath,  the  affusit)n,  and  at  last  the  douche. 
The  friction  with  the  hands  directly  in  contact  with  the  skin  or 
over  a  large  towel,  after  the  douche,  should  always  be  kept  up  until 
the  patierit  is  thoroughly  diy  and  warm. 


' 


88 


PULMONARY   TUBEKCULOSIS. 


Horn  bad 
caUsrs. 


w 


I-ack  oi 
humiility  in 
ntioor 
atmosphere 
a  cause  of 
iiaso- 

pharyiiKcal 
catarrlis. 


Phlhisio- 
Kenesic  ili-- 
uases. 


ChildrtMi  and  young  jjcople  often  develop  tuberculosis  for  no 
other  reason  than  that  they  are  naturally  bad  eaters.  Kind  and 
persistent  ur;^nng  to  cat  a  fairly  hearty  meal  at  least  twice  a  day, 
combined  with  discipline  in  regard  to  regularity  of  meals  and  the 
proper  kind  of  food;  the  exclusion  of  all  delicacies  and  sweetmeats 
tending  to  impair  the  appetite  or  digestion,  associated  with  a  con- 
tinued course  in  aero-  and  hydro-therapeutics,  will  make,  in  a  rela- 
tively short  time,  a  well  and  strong  individual  out  of  a  naturally 
bad  eater.  At  times,  of  course,  tonics,  cod-liver  oil,  iron,  phosphates, 
etc.,  may  be  needed  to  serve  as  adjuvants  in  this  treatment. 

What  has  been  said  of  the  value  of  air-  and  sun-baths — tha  v 
the  judicious  exposure  of  the  whole  cutaneous  surface  of  the  ^'"i 
to  the  air  and  all  except  the  head  to  the  rays  of  the  sun  for  v^.y 
small  children  (page  82) — is  equallj'  true  of  these  bad  eaters  so  long 
as  they  remain  such.  The  tonic  effects  of  sun-baths  are  too  often 
underestimated,  and  the  parents  of  such  children  may  well  take  to 
heart  the  Persian  proverb,  "  Where  the  sun  and  the  air  do  not 
enter,  the  physician  enters  often." 

The  exceedingly  dry  atmosphere  in  the  majority  of  our  American 
private  dwellings  during  the  winter  season  is  a  not  infrequent  cause 
of  chronic  nasopharyngeal  catarrhs,  so  dangerous  to  predisposed 
individuals. 

Already  in  1836,  Dr.  Reid,  of  London,  remarking  upon  the  ven- 
tilation of  the  House  of  Lords,  said  :  "  When  water  to  the  amount 
of  seventy  gallons  was  evaporated  into  the  air  at  a  single  sitting, 
coughing  among  the  members  was  much  diminished."  While 
simple  evaporating  devices,  such  as  a  vessel  filled  with  water  and  a 
cloth  suspended  above  it  touching  the  water  so  as  to  produce  capil- 
lary attraction,  will  answer  all  practical  purposes  of  rendering  the 
atmosphere  sufficiently  humid.  Dr.  Barnes'  liumidifier  has  certain 
additional  advantages.  With  the  aid  of  this  instrument,  wiiicli  we 
will  describe  in  our  chapter  on  the  "  Treatment  at  Home,"  the 
humidity  of  the  atmosphere  in  an  apartment  can  be  regulated  more 
precisely. 

We  must  mention  yet  under  prophylactic  treatment  the  particular 
care  which  should  be  taken  with  patients  recovering  from  diseases 
which  might  be  called  phthisio-genesic.  Nearly  all  eruptive  dis- 
eases of  childhood  and  adult  life,  such  as  measles,  scarlatina, 
variola,  typhoid  fever,  and  typhus,  leave  the  patient  only  too 
frecjuently  predisposed  to  the    invasion    of  the    tubercle    bacilli. 


PREVENTIVE  TKEATMENT.  89 

Severe  grippe  should  also  be  classed  with  the  diseases  predispos- 
ing to  pulmonary  tuberculosis.  Such  patients  should  be  particu- 
larly warned  not  to  expose  themselves  to  the  possibility  of  infec- 
tion. They  should  lead  a  most  hygienic  life,  and  be  careful  not  to 
overexert  themselves. 

As  a  predisposing  cause  to  pulmonary  tuberculosis  we  have 
already  mentioned  syphilis  and  alcoholism.  While  individual 
prophylaxis  may  in  a  measure  be  a  protection  against  these  two 
afflictions,  public  hygiene  and  State  medicine  will  have  to  deal 
with  these  subjects,  as  has  been  already  pointed  out  in  the  chapter 
on  Public  Prophylaxis  (chap,  v). 


Mi 


^'1 


mi 


m 


.i 


CHAPTER  Vlir. 


VISITS  TO  SOME  OF  THE  MOST  IMPORTANT  SANATORIA 

AND  SPECIAL  HOSPITALS  OF  EUROPE,  THE 

UNITED  STATES,  AND  CANADA. 

Nothing  is  more  instructive  to  the  physician  interested  in 
modern  phthisio-therapy  than  a  visit  to  the  sanatoria,  special 
hospitals,  and  health  resorts  devoted  to  the  treatment  of  consump- 
tive patients.  As  stated  in  the  introduction,  I  have  visited  some 
thirty-odd  of  such  places  in  ICurope  and  the  United  States,  in 
order  to  become  acquainted  with  the  best  possible  methods  of 
treatincj  tuberculous  patients. 

Since  it  is  not  possible  for  all  physicians  to  undertake  such 
journeys,  I  shall  endeavor,  in  the  followinj^  pages,  to  describe  and 
illustrate  some  of  the  most  important  and  interesting  institutions 
which  I  visited  four  years  ago,  preparatory  to  my  French  book  on 
sanatoria,  and  some  which  I  have  visited  since.  I  shall  ako 
describe  a  few  which  have  been  established  more  recently.  For 
the  information  concerning  these  I  am  indebted  to  tlie  respective 
inspectors  of  the  institutions.  Thus,  I  hope  to  make  this  chapter 
of  visits  to  sanatoria  as  interesting  and  complete  as  possible. 


EUROPE. 

FALKENSTEIN  SANATORIUM. 

Falkenstein  is  the  Mecca  of  phthisio-therapeutists.  Ail  those 
who  desire  to  instruct  themselves  in  sanatorium  management  and 
tnthe  treatment  of  tuberculosis  will  pay  a  visit  to  Falkenstein  and 
to  Its  ver-erable  director,  Geheimrath  Dr.  Dcttweiler. 

The  sanatorium  is  situated  in  the  village  of  Falkenstein,  about 
thirteen  hundred  feet  above  the  level  of  the  sea,  on  the  southern 
slope  of  the  Taunus  Mountains.  The  valley  is  protected  on  the 
west,  nf)rth,  and  east,  and  opens  toward  the  southeast.  On  each 
side  ri.>ie  wooded  mountains,  which  inclose  a  most  beautiful  view  of 
the  plain.  In  the  foreground  lies  Cronberg  (terminus  of  the  railway 
to  Frankfort),  with  its  castle;  and  beyond,  the  broad  valley  of  the 

90 


IMPORTANT   SANATORIA    AND   SPECIAL    HOSPITALS. 


9' 


Main,  dotted  with  towns  and  villages.  A  little  farther  to  the  east 
the  view  even  extends  to  the  plains  of  the  Rhine. 

The  institution  proper  consists  of  a  main  buildinfj  with  two 
wings  joining  at  an  obtuse  angle  so  as  to  inclose  a  large  terrace, 
and  two  annexes,  united  to  the  main  building  by  covered  prom- 
enade-galleries, opening  toward  the  south.  On  the  east  side,  in 
direct  conmuinication  with  the  main  building,  is  the  new,  elegant 
dining-hall,  and  the  model  kitchen  and  store-rooms.  In  the 
dining-hall,  which  is  78  feet  long,  39  feet  wide,  and  32  feet  high, 
200  persons  can  be  comfortably  seated.  It  is  well  ventilated  and 
in  winter  is  heated  by  steam. 

In  the  main  building  on  the  ground-floor  are  drawing-,  music-, 
and  reading-rooms ;  the  library,  with  2000  volumes  in  iMiglish, 
I'Vench,  and  German;  the  inspector's  office,  and  the  post-  and 
telegraph-offices. 

The  terrace  inclosed  by  the  wings  of  the  main  building  has  an 
especially  protected  situation.  Around  it  exteml  covered  verandas 
provided  with  curtains,  so  that  even  the  weaker  patients  may  be 
able  to  remain  in  the  open  air  from  morning  until  night,  winter 
and  summer.  Similar  structures  and  revolving  pavilions  are 
situated  near  the  building,  and  serve  the  same  purpose.  In  these 
and  the  verandas  are  placed  comfortable,  cushioned,  cane  reclining 
chairs.  These  chairs  enable  the  patients  to  carry  out  with  comfort 
the  main  part  of  the  treatment — namely,  the  prolonged  sojf)urn  in 
the  o[)en  air. 

Through  a  gallery,  200  feet  in  length,  the  eastern  annex  is 
reached,  which  lies  immediately  on  the  border  of  the  forest.  This 
building,  formerly  occupied  by  the  physicians,  is  now,  since  the 
completion  of  the  new  structure,  exclusiveh-  reserved  for  patients. 
These  rooms  are  heated  bj'  hot-water  pipes,  as  in  the  lower  story 
of  the  main  building.  The  halls,  main  stairca.se,  and  corridors  are 
heated  by  the  Bacon  system  of  steam. 

To  the  southwest  of  the  main  building,  and  united  to  it  by  a 
gallery  108  feet  long,  is  the  western  annex.  The  basement  of  this 
annex  contains  the  bath-rooms  and  arrangements  for  the  hydro- 
therapeutic  applications,  which  form  part  of  the  treatment.  The 
institution  has  its  own  water-supply,  derived  from  springs  situated 
250  feet  above  the  sanatorium,  on  the  slope  of  the  "  Altkonig." 
The  water  is  excellent,  and  has  a  temperature  of  50^  to  54°  V.  On 
the  ground-floor  are  the  waiting-  and  consulting-rooms  and  the 


1!:*    i 


■  •,  h 


ll  1i 


I  11! 


|i 


i    i-; 


92 


rUI.MONAKV   TUUKRCUI.OSIS. 


IMPORTANT   SANAIORIA    AND    Sl'FXIAr     HOSIMTAI.S. 


I 


chemical  ami  microscopical  laboratories.  The  upper  lloors  ate 
occu[)iecl  by  the  physicians  and  their  families. 

Ikhind  these  biiiklin'^s,  forming;  together  a  semicircle  open 
towaril  the  valley,  are  the  barns,  stables,  disiiifectint;  apparatus 
(Bacon  system  with  superheated  steam),  and  the  washing'- and  dry- 
ing-rooms.    The  entire  institution  is  li<^hted  by  electricity. 

In  1883,  W.  II.  Lindley,  C.  Iv,  constructed  a  .system  of  draina<je 
ft)r  the  institution  on  the  principle  of  chemical  precipitation,  with 
clearing-basins.     The  system  has  proveil  to  be  most  satisfactory. 

The  sanatorium  is  surrounded  by  grounds  and  woods  in  which 


I 


l'\C,.    17.— \'KRANI)A    AT    I' Al  K  I- NS  I  KIN. 


there  are  many  chann'.ig  walks,  ami  the  adjoining  mountains 
afford  ample  opporvuiiti's  for  pleasant  excursions.  The  climate  is 
essentially  that  of  Ct.p.(.ral  German)'.  Its  main  advantage  is  its 
pure  atmosphere,  free  from  dust.  The  variations  of  temperature 
are  rarely  gr'-at  or  sudden,  and  there  is  no  perceptible  fall  of  tem- 
perature at  sunset  at  Falkenstein. 

The  evenings  are  characterizeil,  almost  the  whule  year  round, 
by  calm  ami  even  temperature.  In  summer  they  are  pleasantly 
cool,  and  in  winter  often  the  most  quiet  part  of  the  day. 

The  institution  is  open  all  the  year  round,  and  patients  are  re- 
ceived at  any  time  as  far  as  room  permits.     During  the  last  year 


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94 


PULMONARV   TUBERCULOSIS. 


the  institution  was  visited  by  some  five  hundred  pat'^nts,  quite  as 
many  remaining  in  winter  as  in  summer. 

Patients  are  not  permitted  to  take  their  meals  in  iheir  rooms 
unless  so  ordered  by  the  physician. 

Friends  and  servants  may  take  rooms  in  the  village  if  their 
constant  presence  with  the  patient  is  not  required.  The  more 
vigorous  patients  may  also,  with  the  consent  of  the  physician,  reside 
in  the  village.  They  lose  none  of  their  privileges  thereby,  nor  are 
they  released  from  their  obligations  as  patients  of  the  sanatorium. 

The  sanatorium  was  founded  in  1874,  through  the  efforts  of  some 
Frankfort  physicians,  with  the  view  of  creating  in  Western  Ger- 
many, in  a  healthy,  mountainous  region  easy  of  access,  an  establish- 
ment for  the  treatment  of  those  suffering  from  disease  of  the  lungs. 
The  capital  necessary  for  the  enterprize  was  principally  subscribed 
by  wealthy  citizens  of  Frankfort,  under  the  condition  that  the  share- 
holders should  not  receive  more  than  five  per  cent,  interest,  and 
that  the  surplus  should  be  used  first  for  the  necessary  improve- 
ments, and  then,  as  soon  as  possible,  for  the  founding  and  maintai  i- 
ing  of  a  sanatorium  for  poor  consumptives.  Thus  was  formed  tlje 
nucleus  of  the  capital  needed  to  create  the  now  so  flourishing 
institution  for  the  consumptive  poor  at  Ruppertshain. 

Since  the  retirement  of  Dr.  Dettweiler  from  the  position  of 
directing  physician,  Dr.  Karl  Hess  has  become  medical  director, 
with  Drs.  Besold  and  Pickert  as  assistant  physicians.  Dr.  Dett- 
weiler still  remains  the  consulting  physician  of  the  institution. 

The  nearest  railway-station  to  Falkenstein  is  Cronberg,  which  is 
about  an  hour's  distance  from  Frankfort-on-the-Main. 


RUPPERTSHAIN  SANATORIUM. 

Ruppertshain  is  the  first  institution  founded  in  Germany  for  the 
treatment  of  the  poorer  classes  of  consumptives.  It  owes  its 
e.xistence  to  the  energy  of  Geheimrath  Dr.  Dettweiler,  his  co- 
laborers,  to  the  generosity  of  the  wealthy  patients  of  Falkenstein, 
and  to  the  philanthropic  citizens  of  Frankfort-on-the-Main. 

The  .sanatorium  of  Ruppertshain  is  situated  at  a  short  di.stance 
from  the  village  of  Ruppertshain,  in  the  Taunus  Mountains.  The 
grounds  on  which  the  buildings  are  constructed  cover  about  twelve 
acres,  anil  are  protected  on  the  north  and  west  by  high,  wooded 
hills,  which  open  toward  the  south.     All  the  buildings  are  con- 


IMPORTANT   SANATORIA   AND   SPECIAL   HOSPITALS. 


95 


!!'' 

nil 

X  )  !  m. 

i    : 

_tJjCZ  : 


96 


PULMONAKY   TUBEKCULOSIS. 


structeil  so  as  to  face  south  or  southwest.  There  is  a  main 
building,  two  pavilions,  and  two  large  galleries,  sheds,  stalls,  etc. 
The  main  building  is  three  stories  high.  The  ground-floor  contains 
douche-rooms,  bath-rooms,  machineries,  etc.  On  the  next  floor 
are  the  reception-rooms,  music-room,  and  jiarlors.  The  rest  of  the 
building  is  taken  up  by  rooms  varying  in  size ;  some  contain  five 
beds,  some  three,  and  some  only  one.  The  bedrooms  arc  light 
and  airy,  about  ten  feet  higii,  and  the  walls  are  painted.  The  floors 
are  of  inlaid  wood,  and  the  ceilings  whitewashed.  There  is  no 
special  arrangement  for  ventilation  except  the  iron  rule,  "  Keep 
window  open  day  and  night."  The  sanatorium  is  heated  by  steam  ; 
it  has  its  own  water-supply  from  one  of  the  mountai'i  sources. 

There  is  a  division  for  men  and  one  for  women.  The  institution 
is  under  the  direction  of  my  former  colleague,  Dr.  Naliin,  of  Falken- 
stein,  aided  by  an  assistant,  and  the  nursing  is  done  by  a  Protestant 
sisterhood.  The  sanatorium  can  accommodate  about  one  hundred 
patients.  Additional  buildings,  to  enlarge  this  capacity  and  to  give 
a  private  residence  to  the  medical  director,  are  projected. 

While  the  interior  arrangements  of  the  sanatorium  at  Rupperts- 
hain  are  not  as  elegant  and  luxurious  as  in  the  mother-institution 
at  Falkenstein,  everything,  though  plain,  is  exceedingly  comfortable 
and  practically  arranged,  .so  that  the  hygienic  and  dietetic  treatment 
can  be  most  carefully  carried  out. 


BREHMER  SANATORIUM,  IN  GOERRERSDORF. 
We  have  already  mentioned,  in  our  historical  chapter,  the  event 
of  the  founding  of  the  first  .sanatorium  for  consumptives,  by  Dr. 
Hermann  Brehmer,  in  1859.  This  institution,  which  is  considered 
to-day  the  largest  of  its  kind  in  the  work!,  being  able  to  accom- 
modate about  250  patients,  had  a  very  small  beginning.  In  1862 
a  new  building  was  added,  and  ever  since  the  institution  has  grown 
and  prospered.  Brehmer  selected  Goerbersdorf  for  his  sanatorium 
because  he  believed  in  the  inmuinity  of  this  mountainous  region, 
and  because  he  found  it  best  adapted  to  carry  out  his  ideas  of  a 
.systematic  ascending  of  graded  walks  in  order  to  strengthen  the 
small  ami  feeble  heart  of  the  consumptive.  According  to  his  idea 
it  was  the  disproportion  between  heart  and  lungs — the  latter  rela- 
tively large,  the  former  small  and  with  weak  muscular  action — which 
was  the  main  etiological  factor  in  the  production  of  pulmonary 
tuberculosis. 


IMHOKTANl"   SANATOKIA    AND   Sl'KClAL    HOSPITALS. 


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Goerbersdorf  is  situated  in  the  southeastern  part  of  Germany,  in 
the  province  of  Silesia,  at  an  altitude  of  1840  feet.  The  natural 
beauty  of  Goerbersdorf  is  certainly  remarkable.  I  visited  the  place 
in  midsummer  and  was  charmed  with  its  climate,  its  hills,  and 
splendid  woods.  At  one  end  of  the  village,  in  the  midst  of  a  beau- 
tiful park,  stands  the  Brehmcr  Sanatorium,  composed  of  a  series  of 
buildings.  The  main  building  is  a  large  Gothic  structure  of  brick, 
which,  I  confess,  did  not  impress  me  as  particularly  well  adapted 
for  a  sanatorium.  The  first  impression  this  vast  structure  makes 
upon  the  visitor  is  that  of  a  fortress  or  castle,  rather  than  a  resi- 
dence intended  for  pulmonary  iin'alids.  The  other  buildings,  as, 
for  example,  "Das  Ncue  Kurliaus,"  the  "White  House,"  "Villa 
Rosa,"  etc.,  are  of  lighter  and  more  pleasing  construction.  Be- 
tween the  old  and  the  new  "  Kurhaus  "  is  a  separate  construction 
surmounted  by  a  tower.  This  wns  the  late  Dr.  Brehmer's  private 
residence,  and  is  to-day  occupied  by  Professor  Kobcrt,  the  director 
of  the  establishment.  The  "White  House,"  "Villa  Rosa,"  etc., 
are  located  in  the  midst  of  the  park  ;  each  of  these  villas  contains 
about  twelve  rooms.  The  i)ark  and  gardens  are  most  beautifully 
kept,  and  one  can  find  therein  so-called  Norwegian  and  .Swiss 
challets,  shady  corners,  sun-boxes,  a  lake  containing  fish,  and 
an  inclosure  for  deer.  On  one  of  the  hills,  about  four  hun- 
dred feet  higher,  is  a  little  Russian  pavilion,  called  the  "  Kath- 
arium,"  from  which  one  has  a  most  beautiful  view  over  the  Giant 
Mountains. 

The  music-rooms,  parlors,  rece[)tion-rooms,  and  bedrooms  are 
elegantly  furnished.  There  is  a  large  library,  numerous  tlouche- 
rooms  and  bath-rooms.  Of  late  there  are  also  galleries  for  the  rest 
cure.  Ik'sides,  there  is  a  beautiful  winter-garden,  of  which  I  give 
a  photograph,  where  the  patients  remain  when  the  weather  does 
not  permit  them  to  be  out-of-doors.  Ventilation,  heating,  and 
illumination  are  in  accordance  with  the  times.  The  disinfection  of 
all  the  apartments  is  regularly  done  with  formaldehyde,  and  with 
the  special  apparatus  designed  by  Professor  Robert.  A  large,  well- 
kept  farm,  belonging  to  the  sanatorium,  is  located  at  some  distance 
from  the  institution.  There  the  kefir  u.sed  in  the  sanatorium  is 
manufactured. 

Besides  the  establishment  f  )r  patients  paying  the  full  price,  there 
has  existed  since  1895  an  anne.x  to  the  Brehmer  .Sanatorium  where 
patients  with  moderate  means  are  received. 


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The  institution  is  under  the  directorship  of  Professor  Rudolph 
Kobert,  who  is  aided  by  five  assistant  physicians. 

Before  closing  the  description  of  Brehmer's  Sanatorium,  I  desire 
to  record  some  of  the  suggestive  maxims  which  the  ingenious 
founder  of  the  institution  has  had  painted  on  the  walls  of  the  apart- 
ments, grottos,  etc.  "  Die  lohnendste  Arbeit  fiir  einen  Kranken 
ist  gesund  zu  tverden."  (The  best  occupation  for  a  patient  is  to 
labor  to  get  well.)  "  VVolle  nur  Eins  und  da.-?  wolle  vom  Herzen." 
(Desire  but  one  thing  and  desire  this  with  all  your  heart.)  Under 
the  medallion  of  Brehmer's  fine  head,  cut  out  of  stone,  is  to  be 
read  :  "  Only  the  physician  who  has  studied  natute  and  has  trained 
his  mind  in  mathematical  science  knows  how  to  cure  men."  Breh- 
mer  himself  was  a  distinguished  mathematician. 

At  the  last  meeting  of  the  Balneological  Society  in  Vienna,  it  was 
decided  to  erect  in  Goerbersdorf  a  monument  to  the  memory  of 
Hermann  Hrehmer,  the  founder  of  modern  phthisio-therapy. 


I 


DR.  ROEMPLER'S  SANATORIUM. 

On  a  somewhat  higher  level  than  the  lirehmer  Sanatorium,  and 
in  a  most  picturesque  spot  in  the  Giant  Mountains,  is  situated  Dr. 
Roempler's  private  sanatorium.  Besides  the  main  building,  more 
lightly  constructed  than  the  Brehmer  Sanatorium,  there  are  several 
pavilions  distributed  throughout  the  park  surrounding  the  sana- 
torium. Along  the  main  building,  facing  southeast,  there  is  a  large, 
comfortable  gallery,  of  which  I  reproduce  a  picture.  Here  the 
patients  take  their  rest  cure.  The  "  Kurhaus  "  proper  is  built  in 
Swiss  challet  style.  Adjoining  this  is  the  winter-garden,  which 
leads  to  the  dining-room,  and  which  is  separate  from  the  other 
buildings.  There  are  several  parlors,  reception-rooms,  billiard-  and 
music-rooms,  and  a  very  well  equipped  library.  The  whole  insti- 
tution is  heated  by  hot  water.  The  hydrotherapeutic  establish- 
ment is  located  in  one  of  the  villas  which  is  centrally  situated. 
The  sanatorium  has  its  own  water-supply,  derived  from  one  of  the 
mountains  near  by. 

The  institution  is  under  the  direct  management  of  Dr.  and  Mrs. 
Roempler,  assisted  by  a  general  physician  and  a  specialist  for  dis- 
eases of  the  throat.  The  sanatorium  can  accommodate  about 
one  hundred  patients.  The  most  modern  sanitary  arrangements 
exist  throughout  the  establishment,  and  the  treatment  pursued  is 


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that  generally  known  as  the  Hrehmcr-Dettvveiler  system.  The 
Roempler  Sanatorium  has  existed  since  1875,  and  is  in  a  very 
flourishing  condition. 


Fni.  2i. — Liii.i-.HAi.Mc  <)i'  Dr.  R(iemii.i;kS  Sanaiukhm. 

The  nearest  railway-station  to  Goerbersdorf  is  Friedland,  on  the 
Breslau-Freiburg  Railroad  ;  but  it  can  also  be  reached  from  Detters- 
bach,  a  station  of  the  Riesengebirge  Railroad. 


SANATORIUM  OF  COUNTESS   PUECKLER  AND  THE  "KRANKEN- 
HEIM"  OF  DR.  WEICKER. 

The  sanatorium  of  Countess  Pucckler  and  t^iat  of  Dr.  Weicker 
are  situated  in  Goerbersdorf,  and  are  both  under  the  direction  of 
Dr.  Hans  Weicker.  The  former  was  founded  through  the  gener- 
osity of  Countess  Pueckler.  It  has  for  its  object  the  treatment 
and  care  of  tuberculous  invalids  coming  from  the  middle  classes. 
It  is  much  smaller  than  any  of  the  others,  and  can  accommodate 
but  thirty  patients.  This  is  in  accordance  with  the  wish  of  the 
founder  as  well  as  of  the  directing  physician,  who  desire  this  sana- 
torium to  resemble  in  a  measure  a  family  home.  Dr.  Weicker 
dines  with  the  patients  of  this  institution  at  the  same  table.  He 
has  inaugurated  so-called  "  zwanglose  Vereinigungen," — that  is  to 


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say,  informal  reunions, — where  patients  ami  pliysicians  meet,  and 
where  hy<;ienic  instructions  are  imparted  to  the  patients. 

Tile  other  institution  i;ndcr  tiie  direction  of  Dr.  Weicker  is  the 
so-called  "  Krankenheim,"  consisting  of  various  villas  distributed 
throughout  the  village  of  Goerbersdorf  The  Krankenheim  is  a 
sanatorium  e.vclusively  for  the  poorer  classc-;  and  only  patients  in 
the  first  degree  of  pulmonary  tuberculosis  are  admitted.  The 
majority  of  these  patients  arc  .sent  here  from  the  State  invalidity  in- 
surance companies  of  Germany,  of  which  we  will  sjieak  more  fully 
when  treating  the  social  problem  of  tuberculosis  (chap.  .\.\v). 
How  much  this  method  of  treating  the  tuberculous  poor  in  the 
earlier  stages  is  growing  in  favor  in  Germany  njay  be  shown  by 
the  statistics  of  the  past  few  years,  as  sent  to  me  very  kindly  by 
Dr.  Weicker : 

In  1894  there  were     12  patients  sent  from  these  companies  to  Dr.  Weitlcer. 

"    1S95         "  66       ••  '•  ••  

••    1896         "          256       '■             "           "               "            '•            " 
"    1897         "  512        "  "  "  

There  is  a  division  for  men  and  a  division  for  women.  Dr. 
Weicker  is  aided  in  his  work  by  two  assistants.  Very  interesting 
is  the  way  in  which  Dr.  Weicker  maintains  discipline  among  his 
patients.  The  inmates  of  each  villa  select  from  their  midst  a 
foreman,  wiio  is  responsible  for  the  order  in  the  house  and  whose 
duty  it  is  also  to  take  the  temperature  of  each  patient  twice  daily, 
and  to  see  that  all  the  directions  of  the  physicians  are  faithfully 
carried  out. 


Ill 


SANATORIUM  OF   HOHENHONNEF, 

Honnef  is  a  little  village  situated  on  the  Rhine,  twenty-five  miles 
south  of  Cologne.  It  is  protected  against  the  cold  winds  of  the 
north  and  east  by  the  Seven  Mountains  (Siebengebirge).  Toward 
the  northeast  of  the  village  is  the  site  of  the  sanatorium,  from 
which  one  has  a  beautiful  view  over  the  valley  of  the  Rhine.  The 
institution  was  opened  in  1892  under  the  direction  of  Dr.  Ernst 
Meissen,  one  of  the  former  assistants  of  Dr.  Dettweiler  at  Falken- 
stein.  Hohenhonnef  has  an  elevation  of  735  feet  above  the  sea- 
level,  and  is  surrounded  by  a  park.  There  are  numerous  prome- 
nades of  various  inclination,  which  ad.ipt  themselves  particularly 
well  to  the  graduated  promenade  exercises  for  the  patients.     The 


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front  of  the  sanatorium  faces  southwest.  There  is  a  central  build- 
ing with  two  wings  forming  obtuse  angles.  The  adjoining  plan 
will  give  a  good  idea  of  the  disposition  of  the  buildings.  The 
main  building  is  so  constructed  that  nearly  all  the  rooms  receive 
sunlight  at  least  for  a  few  hours  during  the  day,  the  majority  hav- 
ing a  southwestern  exposure.  The  bedrooms  are  large,  twelve 
feet  high,  and  are  comfortably  furnished.  There  are  double 
windows  and  double  doors.  The  whole  establishment  is  heated  by 
hot  water,  but,  besides  this,  each  room  has  its  own  open  fireplace, 
its  own  ventilating  shaft,  and  its  own  hot  water  pipe,  so  that  tem- 
perature can  safely  be  regulated  according  to  requirements.  The 
movable  upper  windows  allow  an  easy  access  of  fresh  air.  The 
sanatorium  has  a  very  large,  comfortable  elevator,  and  the  whole 
institution  is  lighted  by  electricity. 

The  gallery  for  the  rest  cure  extends  along  the  main  front,  and 
has  room  for  one  hundred  rattan  lounges  (Liegesessel).  In  the  base- 
ment are  the  douche-rooms,  inhalation-rooms,  etc.  In  the  western 
portion  of  the  first  floor,  facing  north,  are  the  rooms  for  the  em- 
ployees, the  laboratories,  drug-room,  and  a  barber-shop.  Facing 
south  are  the  reception-rooms,  parlors,  library,  billiard- and  music- 
rooms.  The  eastern  portion  of  the  lower  floor  contains  nine  bed- 
rooms. The  upper  stories  contain  seventy-five  bedrooms  for 
patients  and  also  the  private  apartments  of  the  medical  director. 
For  the  present  the  sanatorium  can  accommodate  about  one  hun- 
dred patients.  Additional  building-;  are  in  course  of  construction. 
All  the  rooms,  and  everything  connected  with  the  institution,  are 
most  hygienically  arranged.  The  floors  of  the  bedrooms  are 
covered  with  linoleum.  All  the  stables,  the  laundry,  and  dis- 
infecting-rojms,  the  machineries,  dynamos,  pumps,  etc.,  are  situated 
nearly  five  hundred  feet  below,  in  the  valley,  in  the  so-called 
"Asbachthal."  A  cable  road  connects  the  Asbachthal  with  the 
institution.  The  sanatorium  can  be  reached  in  twenty  minutes 
from  Honnef,  which  is  a  railroad-station  ;  also  from  Konigswinter, 
which  lies  at  a  distance  of  forty  minutes.  Konigswinter  is  also  a 
station  for  steamboats  plying  on  the  Rhine. 


ti  ■ 


IMPOKTANT   SANATORIA    AND   SPECIAL   HOSPITALS. 


109 


SANATORIUM  OF  REIBOLDSGRUN. 

Reiboldsgriin  is  situated  in  the  southern  portion  of  the  king- 
dom of  Saxony,  in  the  Erzgebirge,  at  an  altitude  of  2460  feet.  The 
sanatorium  was  founded  in  1873  by  Dr.  Driver,  and  is  now  under 
the  able  direction  of  Dr.  Felix  VVolff-Immermann,  who  is  aided  by 
two  assistants. 

Reiboldsgriin  is  most  beautifully  and  picturesquely  situated. 
It  is  surrounded  by  a  dense  pine-forest.     There  are  no  habitations 


Fig.  27.— Sanatorium  at  Reiboldsgkun. 


near  by,  and  the  nearest  village  is  at  an  hour's  distance.  Thus, 
the  sanatorium  is  unique  in  its  kind  in  Germany;  the  various  build- 
ings, eight  in  number,  form  a  little  village  by  themselves. 

The  "  Kurhaus,"  which  represents  the  main  building,  contains  a 
large  dining-room,  parlors,  music-room,  and  kitchen.  In  connec- 
tion with  the  main  building  is  the  villa  "  Winterheim,"  a  three- 
story  structure  with  twenty-four  rooms  for  the  patients.  In  the 
lower  story  are  the  consultation  room,  reception-room,  and  drug- 
room.  From  the  Winterheim  covered  glass  galleries  lead  to  the 
rest-cure  verandas  and  to  the  other  buildings,  such  as  villa 
"  VViesenhaus,"  vilia   "  Hugosruhe,"  etc.      There   are   four   more 


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villas  of  smaUer  sizes:  villa  "  Thurmhaus,"  with  twenty  rooms ; 
villa  "  Karlsruhe,"  with  twelve  ;  villa  "  Mathildenruhe,"  which  is  the 
residence  of  the  former  director,  Dr.  Driver,  and,  lastly,  the  private 
cottage  of  Dr.  Wolff. 

At  some  distance  from  these  buildiny;s  are  the  laundry,  the  dis- 
infecting-room,  and  the  stables.  The  park  in  which  the  sanatorium 
is  situated  extends  over  five  hundred  acres.  There  is  now  room 
for  about  one  hundred  patients,  but  since  my  last  visit  to  Reibolds- 
griin  Dr.  Wolff  wrote  me  that  plans  were  in  readiness  to  erect 
other  and  more  expensive  buildings. 

The  country  surrounding  Reiboldsgriin  offers  many  interesting 
places  for  excursions.  The  social  life  in  Reiboldsgriin  is  particu- 
larly pleasant;  Dr.  Wolff,  himself  an  accomplished  musician, 
frequently  organizes  concerts,  theatricals,  etc.  There  are  several 
pianos  and  an  organ  in  the  institution. 

As  an  anne.x  to  the  sanatorium  we  must  mention  Zoebisch,  a 
little  colony  of  friends  of  patients  residing  in  the  sanatorium 
grounds,  with  a  sprinkling  of  convalescent  patients  among  them, 
who,  while  still  under  the  doctor's  care,  have  graduated  from  the 
sanatorium,  and  do  not  any  longer  require  the  strict  supervision. 

Near  the  sanatorium  there  is  a  natural  spring  containing  iron 
salts.  The  water  is  utilized  for  the  especially  anaemic  invalids  of 
the  sanatorium.  The  spring  enjoyed  a  reputation  even  before  the 
erection  of  the  sanatorium.  Reiboldsgriin  is  eight  miles  from 
Rautenkranz,  a  station  of  the  Chemnitz-Adorfer  Railway,  and 
twelve  miles  from  Auerbach,  a  station  of  the  Zwickau-Oelsnitzer 
Railway. 

ALBERTSRERG  SANATORIUM. 

A  few  hours  distant  from  Reiboldsgriin,  at  Albertsberg,  near 
Auerbach,  is  located  the  new  sanatorium  for  the  consumptive  poor 
of  the  kingdom  of  Saxony.  Its  erection  is  largely  due  to  the 
generosity  of  the  King  of  Saxony,  who  endowed  the  institution, 
and  who  seems  to  take  particular  interest  in  the  social  problem  of 
pulmonary  tuberculosis.  The  institution  was  inaugurated  in  Octo- 
ber, 1897,  and  can  accommodate  eighty  patients.  It  resembles,  in 
its  exterior  and  interior  arrangements,  the  sanatoria  devoted  to  the 
treatment  of  the  richer  classes,  and,  while  there  is  less  elegance, 
the  patients  are  most  comfortably  situated.  The  direction  of  the 
institution  is  in  the  hands  of  Dr.  Gebser,  a  former  assistant  at  Rei- 
boldsgriin. 


i^^ 


112 


PULMONARY   TUBERCULOSIS. 


DR.  HAUFFE'S  SANATORIUM  AT  ST.  BLASIEN. 

Dr.  Hauffe's  sanatorium,  which  I  visited  in  July,  1895,  when  it 
was  still  under  his  direction,  has  now  passed  into  the  hands  of  Dr. 
Sanders.  St.  Blasien  is  situated  at  the  foot  of  the  Feldberg,  one 
of  the  mountains  of  the  Black  Forest.  The  valley  is  called  the 
Valley  of  the  Alb,  and  has  an  altitude  of  2500  feet  above  sea-level. 
The  Black  Forest  is  known  for  its  natural  beauty,  and  St.  Blasien 
especially  for  its  mild  climate.  The  air  is  particularly  rich  in 
ozone,  and  the  surrounding  pine-forests  produce  an  atmosphere 
laden  with  the  pleasant,  health-giving  odor  of  these  trees. 

The  buildings  of  the  sanatorium  are  situated  on  a  somewhat 
higher  level  than  St.  Blasien,  which  is  itself  a  health  resort  much 
frequented  by  neuropaths.  This  proximity  to  a  very  noisy  and  gay 
health  resort,  where  dancing  and  sports  of  all  kinds  are  much  in 
vogue,  might  be  considered  an  objection  for  a  sanatorium  for  con- 
sumptives. Aside  from  this.  Dr.  Hauffe's  institution  offers  all  the 
advantages  of  tiie  other  closed  establishments  for  the  cure  of  con- 
sumptives. The  sanatorium  is  composed  of  a  scries  of  buildings 
united  by  a  glass  gallery  and  a  veranda  for  the  "  Liegekur."  In 
addition  to  this,  every  story  has  balconies  which  serve  as  places 
for  the  feebler  patients  to  take  their  open-air  treatment.  The 
equipment  of  the  bedrooms,  parlors,  library,  etc.,  is  in  accordance 
with  the  special  hygiene  to  be  observed  where  tuberculous  patients 
congregate.  There  are  no  draperies,  no  carpets  (except  a  few 
rugs),  and  the  floors  of  corridors  and  rooms  are  covered  with  lino- 
leum. There  are  special  arrangements  for  ventilation  by  a  sort  of 
transom  over  the  windows;  all  the  other  hygienic  arrangements 
concerning  the  sputum,  etc.,  are  those  in  vogue  in  most  of  the 
sanatoria  in  Germany.  The  institution  is  lighted  by  electricity, 
and  the  water-supply  is  excellent.  There  are  kiosks  and  benches 
distributed  in  a  garden  and  park  near  by. 

Under  the  management  of  Dr.  Hauffe  the  sanatorium  accepted 
even  the  most  advanced  cases ;  but  Dr.  Sanders  wrote  me  recently 
that  he  had  departed  from  this  policy,  and  only  accepts  patients  in 
the  earlier  stages  of  the  disease  who  have  a  reasonable  cliance  of 
recovery.  He  wishes  to  make  the  institution  a  sanatorium — that  is 
to  say,  a  healing  institution  in  the  highest  sense  of  the  word. 

The  village  of  St.  Blasien  is  of  ancient  origin.  Its  church  and 
cloisters,  which  date  from  the  eleventh  century,  are  still  in  good 


IMPORTANT   SANATORIA   AND   SPECIAL    HOSPITALS. 


"3 


preservation.  St.  Liasien  has  no  railway-station.  The  nearest 
one,  at  Albbriick,  on  the  Hasel-Constance  Railway,  is  at  a  distance 
of  about  twelve  miles.  Another  station  is  Titisee,  ;it  a  distance  of 
fourteen  miles  from  St.  Blasien,  on  the  Freiburg-Neustadt  line. 


DR.  OTTO  WALTHER'S  SANATORIUM. 

Dr.  VValther's  institution,  which  is  situated  in  Nordrach,  in  the 
Black  Forest,  is  also  known  by  the  name  of  the  "  Nordrach  Col- 
ony." It  is  at  an  elevation  of  1500  feet  and  commands  a  beautiful 
view  of  the  valley,  opening;  toward  the  south  and  southwest.  It 
consists  of  a  series  of  small  buildings  situated  at  considerable 
distance  from  each  other.  There  is  a  central  building  which  con- 
tains the  dining-room  and  administration-rooms.  There  are  no 
galleries  for  the  rest  cure  as  in  other  institutions,  but  some  of  the 
rooms  have  balconies.  In  the  equipment  of  the  rooms  much 
attention  has  been  paid  to  hygienic  arrangement,  even  to  the  furni- 
ture. Linoleum  on  the  floor,  plain  walls,  iron  bedsteads,  etc.  The 
"  Liegesessel  "  remain  in  the  rooms,  which  are  constantly  well 
aired.  Dr.  Walther  trains  his  patients  so  that  they  can  even  stand 
drafts.  He  ascribes  the  majority  of  colds  rather  to  the  enfeebling 
of  an  organism  by  too  much  exercise  than  to  the  sudden  changes 
of  temperature. 

The  Nordrach  Colony  is  surrounded  by  a  beautiful  forest,  which, 
however,  is  at  a  sufficient  distance  to  allow  plenty  of  sunlight  for 
the  whole  colony.  There  is  a  douche-  and  bath-room  with  each 
bedroom.  All  the  buildings  are  heated  by  steam,  which  comes 
from  the  central  building.  The  sanatorium  has  also  its  own 
electrical  plant,  dairy,  steam  laundry,  and  also  an  ice  manufactory. 

The  institution  is  very  flourishing  and  is  much  visited  by  Amer- 
ican and  English  patients.  A  lady  teacher  is  attached  to  the  insti- 
tution to  teach  the  children,  who  are  either  patients  or  have  come 
with  their  parents.  Dr.  Walther's  sanatorium  can  accommodate 
aboi;t  forty  patients.  The  nearest  railway-station  to  Nordrach  is 
Gengenbach,  on  the  Black  Forest  Railroad. 


! 


-'I 


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114 


PULMONARY   TUBERCULOSIS. 


m 


ODERBERG  SANATORIUM. 

In  describing  the  "  Krankenheim  "  at  Goerbersdorf,  I  mentioned 
the  work  done  by  the  State  invaUdity  insurance  companies  of 
Germany  in  relation  to  sanatoria  for  the  treatment  of  tubercu- 
lous patients.  The  first  insurance  company  which  undertook  the 
creation  of  its  own  sanatorium  for  its  tuberculous  clients  was  the 
"  Hanseatische  Versicherungsanstalt  fiir  Invaliditats-  und  Alters- 
versicherung  "  of  Liibeck.  The  company  selected  a  beautiful  site 
in  the  Harz  Mountains  near  St.  Andreasberg,  and  built  the  institu- 
tion on  the  slope  of  the  Great  Oderberg,  at  an  altitude  of  nearly  two 
thousand  feet.  The  surrounding  mountains  and  woods  protect  the 
sanatorium  from  cold  winds.  The  institution,  of  which  I  give  an 
illustration,  is  most  interestingly  situated  and  managed.  There 
is  a  main  building  consi.sting  of  a  central  portion  and  two  annexes. 
To  the  west  and  communicating  with  the  annex  is  the  machinerj'- 
room  and  laundry.  To  the  south,  .separated  from  the  main  build- 
ing, is  the  residence  of  the  physician-in-chief  At  a  distance  of 
about  fifty  feet  to  the  west  of  the  machine-room  are  the  disin- 
fecting- and  autopsy-rooms.  About  three  hundred  feet  to  the 
northwest  of  the  main  building  is  a  building  which  is  occupied 
by  the  employees  and  their  families,  and  nearly  five  hundred 
feet  to  the  west  are  located  the  stables.  The  buildings  occupy  an 
area  of  about  eight  or  nine  acres. 

The  principal  building,  facing  south,  is  a  four-story  structure. 
In  the  basement  are  the  kitchen  and  the  store-rooms.  The  first 
story  contains  consultation-,  administration-,  and  dining-rooms. 
In  the  annexes  on  the  first  story  are  the  bedrooms  for  the  patient.'^. 
The  second  story  of  the  central  building  is  occupied  by  the  general 
superintendent  and  the  assistant  physicians.  The  east  side-wing 
contains  a  large  parlor  and  promenade  corridor.  The  rest  of  the 
building  consists  of  bedrooms  for  i)atients.  There  are,  in  all,  seven 
rooms  with  one  bed  each,  fourteen  rooms  with  two  beds  each,  six 
with  three  beds  each,  and  fourteen  with  four  beds  each.  Besides 
these  there  are  four  bedro<Miis  reserved  for  the  purpose  of  isolating 
patients.  Thus,  about  one  hundred  and  ten  patients  cpn  be  accom- 
modated. The  interior  equipment  of  the  institution  is  i)lain,  com- 
fortable, and  hygienic.  The  ventilation  in  all  the  rooms  is  perfect; 
the  heating  is  done  by  steam,  and  the  establishment  is  lighted  by 


IMPORTANT   SANATORIA    AND   SPECIAL    HOSPITALS. 


115 


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I  i   < 


Ii6 


PULMONARY   TUBERCULOSIS. 


electricity.  It  has  also  an  excellent  water-supply  and  a  good  drain- 
age system. 

In  imitation  of  Goerbersdorf,  the  walls  are  ornamented  with 
suggestive  verses.  So,  for  example,  we  read,  in  the  dining-room, 
"  Allen  Menschen  Recht  gethan,  ist  eine  Kunst  die  Niemand 
kann  "  (To  please  and  suit  each  single  one,  is  science  understood 
by  none).  At  another  place  we  find  the  following  :  "  Streng  gegen 
Dich,  gerecht  gegen  Alle "  (Be  severe  with  yourself  and  just 
toward  others).  "  Zwei  Dinge  lern  geduldig  tragen  :  Dein  eignes 
Leid,  der  Andren  Klagen  "  (Two  things  try  to  bear  with  resigna- 
tion :  your  own  misfortune  and  others'  lamentation).  There  are 
other  maxims  inscribed  on  the  walls  referring  to  intemperance, 
cleanliness,  the  value  of  fresh  air,  etc.,  which  space  forbids  us  to 
reproduce  here. 

In  front  of  the  building  is  a  large,  covered  gallery,  and  along  the 
east  and  west  sides  of  the  house  are  the  galleries  for  the  rest  cure 
and  promenade  exercises  on  rainy  days.  The.se  galleries  have  a 
length  of  410  feet  and  are  nearly  twelve  feet  wide.  There  is  a  large 
square  in  front  of  the  sanatorium,  which,  being  especially  pro- 
tected against  cold  winds,  is  a  favorable  place  for  patients  to  take 
their  promenades. 

The  discipline  in  this  institution  is  maintained  in  a  somewhat 
similar  way  to  that  in  vogue  in  the  Krank'iiheim  of  Dr.  Weicker. 
A  certain  number  of  patients  .select  a  foreman,  who  is  responsible 
to  the  physicians  and  the  general  superintendent  (two  distinct 
offices)  for  the  carrying  out  of  the  general  and  medical  directions 
on  the  part  of  the  patients.  The  treatment  in  the  institution  is  the 
hygienic  and  dietetic  treatment  as  in  all  sanatoria,  and  the  patients 
are  sent  to  the  institution  in  the  very  earliest  stages  of  the  disease 
— that  is  to  say,  as  soon  as  the  medical  examiner  of  the  insurance 
company  is  able  to  detect  it. 


SANATORIUM  OF  CANIGOU. 

This  is  the  first  institution  which  was  founded  in  France  where 
the  hygienic  and  dietetic  treatment,  according  to  the  principles 
laid  down  by  Brehmer  and  Dettweiler,  were  carried  out.  This  is 
done  with  as  much  rigor  as  the  peculiar  arrangement  of  the 
Canigou  institution  will  permit. 

I  visited  Canigou  in  the  spring  of  1895,  when  the  institution  was 


IMPORTANT   SANATORIA    AND   SI'ECIAI.    HOSPITALS. 


1 1: 


still  under  the  direction  of  Dr.  Sabourin,  who  has  now  a  sanatorium 
at  Durtol,  in  the  department  of  Puy-de-D6me,  known  by  the  name 
of  "Sanatorium  du  Chateau  de  Durtol." 

The  present  director  of  tlie  sanatorium  of  Canigou  is  Dr. 
Giresse.  The  peculiarity  of  this  institution  is  tliat  tlie  gallery  for 
the  rest  cure  is  situated  several  hundred  feet  higher  than  the  main 
building,  which,  in  reality,  is  a  hotel.  The  patients  take  their  early 
breakfast  here,  and  then  proceed  to  the  gallery.  The  next  meal, 
which  is  served  at  noon,  though  called  dejeuner,  has  an  elaborate 
menu  and  is  served  in  the  dining-room  annexed  to  the  veranda  for 


m  II 


1^ 

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Fig.  30. — Rkst  Clrk  Gai.i.kry  ok  thk  Canii;ou  Sanatorii'M. 


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the  rest  cure.  Toward  evening  the  patients  descend  to  take  their 
dinner  at  the  hotel  where  they  reside.  Many  of  them  are  strong 
enough  to  make  their  ascent  and  descent  on  foot,  while  the  feebler 
ones  are  conveyed  in  a  closed  omnibus.  Aside  from  this  the 
patients  are  treated  as  in  the  German  sanatoria,  and  while  the 
meals  are  arranged  according  to  the  French  fashion, — "  premier 
dejeuner  "  at  8  o'clock  in  the  morning,  "  dejeuner  "  at  i  o'clock,  and 
dinner  at  6  p.m., — the  suralimentation  is,  nevertheless,  adhered  to. 
At  about  4  o'clock  the  patients  take  a  lunch  consisting  of  raw 
chopped  meat  with  bread  and  butter,  and  throughout  the  day  they 


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Ii8 


PULMONARY   TUBERCULOSIS. 


drink  a  good  deal  of  milk  between  meals.  Sabourin  instituted  the 
use  of  hot-water  cans  to  be  put  at  the  feet  of  the  patients  on  very 
cold  days,  when  taking  their  rest  cure.  The  physician  spends  a 
good  deal  of  his  time  with  the  patients  up  in  the  mountain  annex, 
but  he  does  not  live  in  the  hotel.  The  institution  can  hardly  be 
called  a  closed  establishment  in  the  sense  of  the  German  interpre- 
tation of  the  term  "  geschlossene  Heilanstalt."  Hut  I  was  assured 
by  some  of  the  patients  that  they  rather  liked  the  change  of  going 
up  and  down,  this  being  a  pleasant  interruption  to  the  rather 
monotonous  mode  of  life  in  the  sanatorium.  They  like  to  com- 
mence their  "jour  medical  "  with  a  slow  ascension  to  the  terrace, 
where  they  have  plenty  of  time  to  rest  on  their  rattan  lounges. 
They  look  forward  to  their  return  to  the  hotel  as  another  pleasant 
change.  The  number  of  patients  at  the  time  of  my  visit  was 
about  seventy. 

During  the  hottest  months  in  summer  the  institution  is  closed ; 
but  aside  from  the  few  very  hot  months  the  climate  of  Vernet-les- 
Bains,  the  village  near  which  Canigou  is  situated,  is  well  adapted 
to  the  treatment  of  tuberculosis.  The  gallery  of  the  sanatorium 
is  at  an  elevation  of  2250  feet  above  the  sea-level,  and  has  a  south- 
western e.\posure.  The  average  temperature  is  42°  F.  for  the 
winter,  58°  for  the  spring,  68°  for  the  summer,  and  46°  for  the  fall. 
There  are  about  six  days  of  snow  and  seventy  days  of  rain  during 
the  year.  The  sanatorium  is  named  after  the  Canigou  Mountain, 
which  is  9135  feet  high.  Vernet-les-Bains  is  a  village  in  the 
Pyrenees  Orientales.  It  has  been  known  for  centuries  for  its 
thermal  waters,  and  is  beautifully  situated  on  the  northwest  end  of 
a  shoulder  of  Mt.  Canigou,  on  the  banks  of  a  stream  called  the 
Casteill.  Vernet-les-Bains  can  be  reached  within  fifty  minutes  from 
Prades,  which  is  the  terminus  of  a  little  railway  starting  from  Per- 
pignan.  The  latter  is  one  of  the  most  important  stations  on  the 
Narbonne-Barcelone  Railroad. 


i    i 


MARITIME   HOSPITAL  OF  BERCK  SUR-MER. 

One  of  the  most  important  institutions  existing  in  P'rance,  and 
perhaps  in  the  world,  devoted  to  the  treatment  of  the  tuberculous 
diseases  of  childhood,  is  the  Maritime  Hospital  of  Berck-sur-Mer. 

While  a  student  in  Paris  I  was  fortunate  enough  to  spend  a  uni- 
versity vacation  in  this  interesting  sea-side  town,  where  no  less  than 


IMPORTANT  SANATORIA    AND   SPECIAL    HOSPITALS. 


119 


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120 


PULMONARY   TUBERCULOSIS. 


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four  largv,  institutions,  exclusively  devoted  to  the  treatment  of 
scrofulous  and  tuberculous  children,  are  situated.  The  largest  and 
most  interesting  one  is  the  above-mentioned,  which  belongs  to  the 
city  of  Paris.  It  is  under  the  able  direction  of  Dr.  D.  Menard,  to 
whom  I  am  greatly  indebted  for  the  many  privileges  and  favors 
granted  to  me  during  my  stay  at  Berck.  It  was  at  this  large  hos- 
pital, which  can  accommodate  from  500  to  600  patients,  that  I  had  an 
opportunity  to  observe  the  beneficial  effect  of  the  sea-coast  air  on 
tuberculous  diseases  of  childhood,  which  were  principally  tubercu- 
losis of  the  joints,  bones,  and  the  glandular  manifestations.  One 
could  see  almost  a  daily  improvement  in  these  little  sufferers  sent 
from  the  great,  crowded  city  hospitals  of  Paris.  It  was  really  as- 
tonishing how  rapid  was  t  le  recovery  of  most  of  the  children  who 
had  undergone  quite  serious  capital  operations,  resections,  amputa- 
tions, etc. 

The  institution  faces  the  ocean.  The  first  small  building  was 
erected  in  1861  by  the  "Administration  de  I'Assistance  Publique." 
Besides  vhis  institution,  entirely  supoorted  by  the  city  of  Paris,  and 
intended  for  the  absolutely  poorti. .  .*  exists  an  additional  hospital 
called  "  I'Hopital  des  Knfants  Assistes."  Here  the  patients  pay  a 
part  of  the  expense.     Both  institutions  are  nearly  always  filled. 

Dr.  Menard  is  as.;isted  by  various  internes  and  externes.  He 
has  the  title  of  Medecin  et  Chirurgien  en  Chef  The  wards  in  the 
Maritime  Hospital  are  large,  well  ventilated,  and  well  kept.  All  the 
convalescent  children  are  permitted  to  bathe  in  the  ocean  during 
the  summer  months. 

The  two  other  hospitals  are  I'Hopital  Rothschild,  which  is  kept 
up  by  the  generosity  of  the  Rothscnild  family  for  the  benefit  of  poor 
tuberculous  children  of  the  Hebrew  faith,  and  another  Roman 
Catholic  institution  maintained  by  the  Sisters  of  Charity.  The  two 
last-named  hospitals  are  under  the  direction  of  Dr.  Calot,  celebrated 
for  his  method  of  forcible  extension  in  spinal  curvatures  caused  by 
Pott's  disease. 


SANATORIUM  Of"  DR.  TURBAN  AT  DAVOSPLaTZ. 

Davos  has  long  been  known  as  a  favorite  ciimatic  resort  for 
tuberculous  patients.  For  the  first  climatic  observations  we  are 
indebted  to  Dr.  Spongier,  which  date  back  to  1862.  In  1H63  a  Dr. 
Unger,  being  consumptive,  went  to  Davos  and  recovered  his  health. 


IMPORTANT   SANATORIA   AND   SPECIAL    HOSPITALS. 


121 


Professor  Jaccoud,  of  Paris,  made  an  extensive  study  of  tlie  cli- 
matic condition  of  the  Davos  Valley,  and  recorded  his  observations 
in  full  in  his  book  on  the  curability  and  treatment  of  pulmonary 
phthisis.  Hermann  Weber,  of  London,  a  distinguished  writer  and 
authority  on  climatology  and  pulmonary  diseases,  discusses  at 
length  the  climate  of  Davos.  I  have  myself  visited  Davos  and 
can  not  but  agree  with  the  authors,  who  consider  this  region  as 
especially  favorable  to  the  treatment  of  pulmonary  tuberculosis 
in  its  earlier  stages.  The  most  interesting  and  important  fact 
which  strikes  the  meteorological  observer  is  the  great  amount  of 
sunshine  which  Davos  enjoys.  While  at  Zurich  the  amount  of 
sunshine  during  the  month  of  November  was  forty-eight  and  one- 
half  hours,  or  an  average  per  day  of  one  hour  and  thirty-six  and 
one-half  minutes,  it  was  at  Davos  one  hundred  and  twenty-eight 
hours,  or  four  hours  and  sixteen  minutes  per  day.*  There  is  but 
little  mist  in  Davos,  and  even  very  low  temperatures  are  well  borne 
by  tuberculous  patients  in  the  dry,  calm  atmosphere  of  this  Alpine 
winter  resort.  It  is  doubtlessly  due  to  the  intense  insolation  that 
one  feels  the  cold  so  much  less  than  at  ordinary  altitudes.  Such  a 
climate,  where  the  patients  can  remain  out-doors  so  many  days 
in  the  year  and  so  many  hours  of  each  day,  must  of  necessity  be 
well  adapted  to  the  hygienic  and  dietetic  treatment  of  tuberculous 
patients. 

In  i88S  the  first  sanatorium  for  the  exclusive  treatment  of  con- 
sumptives was  erected  at  Davosplatz  by  Hofrath  Dr.  Turban.  To 
the  honor  of  Dr.  Turban  may  it  be  said  that  the  sanatorium  is  in 
the  highest  sense  a  closed  establishment,  for  in  none  of  the  many 
sanatoria  I  have  visited  in  Europe  and  in  the  United  States  have  I 
seen  a  more  rigid  discipline  prevail  than  in  Dr.  Turban's  .sanatorium. 
It  is  situated  to  the  southwest  of  Davosplatz,  and  at  an  altitude  of 
51  i5  feet;  well  protected  from  the  winds,  it  is  also  at  a  suflKcient 
distance  from  other  habitations.  The  building  was  erected  by 
Erdmann  Hartig,  of  Brunswick,  a  distinguished  architect.  Look- 
ing toward  the  south  one  has  from  the  sanatorium  a  vast  and  beau- 
tiful view  of  the  Davos  Valley  and  the  high,  encircling  mountains. 
The  building  itself  is  surrounded  by  a  well-kept  garden  with  grad- 
uated promenades,  benches,  and  kiosks.  The  principal  building 
faces  south.     It  is  four  stories  high  and  communicates  with  two 


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*  \Vcl)er,  "  Croonian  Lectures." 


122 


PULMONARY  TUBERCULOSIS. 


villas  by  closed  galleries;  the  one  situated  toward  the  west  is 
occupied  by  Dr,  Turban  and  his  family;  the  one  toward  the  east 
by  patients.  In  front  of  the  main  building  are  the  galleries,  250 
feet  long,  where  the  patients  take  their  rest  cure.  In  the  base- 
ment are  the  offices,  the  laundry,  and  the  kitchen.  The  first  story 
contains  a  large  dining-room  forty-eight  feet  long,  thirty  feet  wide, 
and  sixteen  feet  high;  also  conversation-rooms,  library,  billiard- 
room,  consultation-room,  laboratory,  and  drug-room,  besides  a 
hydrotherapeutic  and  gymnastic  institution.     In  the   upper  story 


Fio.  32.— Or.  Tikban's  Sanatorum,  Davospi.atz. 


of  the  main  building  all  the  bedrooms  face  south,  while  on  the 
north  there  is  nciing  but  a  large  corrrdor.  Nearly  all  the  rooms 
have  balconies.  The  equipment  of  the  rooms  is,  of  course,  also 
thoroughly  hygienic.  There  is  a  special  heating  and  ventilating 
apparatus,  whereby  the  temperature  of  the  cold  air  commg  from 
the  outside  is  regulated.  The  whole  establishment  is  lightetl  by 
electricity.  At  a  distance  from  the  main  building  is  to  be  found  a 
good  disinfecting  apparatus.  The  sanatorium  can  accommodate 
seventy  patients. 


IMPORTANT   SANATORIA   AND   SPECIAL   HOSPITALS.  I  23 

A  unique  institution  at  Dr.  Turban's  sanatorium  is  his  class  of 
"  Prophylaktiker."  This  comprises  the  children  of  his  tuberculous 
patients,  whom  he  educates  physically  and  intellectually,  so  that  they 
will  not  become  consumptive  like  their  parents.  For  the  last  few 
years  Dr.  Turban  has  not  admitted  any  advanced  cases  into  his 
institution.  Besides  Dr.  Turban  there  is  an  assistant  physician  in 
constant  attendance.  Davosplatz  is  the  terminus  of  the  Right 
Landquart-Davos  Railroad. 


SANATORIUM  AROSA. 

To  the  west  of  Davos  is  the  valley  of  Arose,  which  has  come 
quite  in  favor  of  late  as  a  winter  resort.  The  difficulty  of  com- 
munication has,  until  some  years  ago,  been  a  hindrance  to  the 
development  of  this  locality.  But  lately  there  has  been  constructed 
a  beautiful  route  between  Arosa  and  Chur,  the  nearest  railway- 
station.  Arosa  can  be  reached  from  Chur  by  stage  or  carriage 
within  five  or  six  hours.  The  valley  of  Arosa  is  surrounded  on 
all  sides  by  an  uninterrupted  mountain  chain  composed  of  snow- 
capped peaks  varying  from  7000  to  10,000  feet  in  height.  The 
valley  itself  has  an  altitude  of  about  six  thousand  feet.  The 
slopes  of  these  mountains  are  covered  with  dense  forests  of 
pine-trees.  At  a  height  of  about  seven  thousand  feet  there 
are  two  beautiful  lakes  with  clear  water,  which  give  a  picturesque 
aspect  to  the  landscape.  Toward  the  southern  slope  of  the 
Tschuggen  Mountain,  at  an  altitude  of  6150  feet,  is  situated 
the  sanatorium,  which  was  constructed  during  the  years  1887  and 
1888.  Thus  protected  from  the  north  by  the  mountain,  it  is  free 
toward  the  south  and  west,  so  that  a  beautiful  panorama  unfolds 
itself  before  one's  eyes.  There  is  a  great  deal  of  sunshine  on  the 
whole  slope  where  the  sanatorium  is  situated,  but,  of  course,  the 
inevitable  Fohn — the  hot,  south  wind  of  the  Alpine  regions — 
is  as  frequent  here  as  anywhere  in  these  high  regions.  Happily, 
the  forests  regulate  and  moderate  the  temperature  of  the  atmos- 
phere, so  that  the  average  and  minimum  temperatures  of  Arosa  in 
winter  are  four  degrees  higher  than  at  Davos,  which  has  an  altitude 
of  nearly  one  thousand  feet  less.  In  sunmier,  on  the  contrary, 
Arosa  is  somewhat  less  warm  than  Davos.  The  atmosphere,  as 
a  rule,  is  calm  in  winter,  and  there  is  relatively  little  rain. 

The  new  sanatorium  is  a  large,  majestic  building,  the  majority  of 


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124 


PULMONARY   TUBERCULOSIS. 


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'  the  rooms  facing  south  and  southwest.  A  few  rooms  have  bal- 
conies, but  each  room  has  its  own  fireplace,  while  the  corridors  are 
heated  by  hot  water.  There  are  dining-rooms,  reception-rooms, 
parlors,  and  a  billiard-room.  There  is  a  covered  veranda  facing 
south,  where  the  chairs  for  the  rest  cure  are  placed.  Here  the 
patients  pass  the  greater  part  of  the  day.  There  is  a  separate 
hydrotherapeutic  establishment  and  also  a  separate  building  for 
disinfecting  purposes.  The  water-supply  and  drainage  system  are 
good.  The  sanatorium  is  now  under  the  management  of  Dr.  E. 
Jacob;,  It  is  open  throughout  the  year,  and  can  accommodate 
sixty-five  patients. 

SANATORIUM  OF  LEYSIN. 

Leysin  is  a  little  village  in  the  Canton  de  Vaud,  in  Switzerland, 
situated  in  a  mountain  valley  at  the  foot  of  high  peaks,  called  the 
Tours  d'Ai.  The  exceptionally  pure  atmosphere  of  this  part  of 
Switzerland  has  been  known  to  the  Swiss  for  years,  and  many  rich 
people  have  erected  villas  near  Leysin,  where  they  spend  part  of  the 
year.  The  sanatorium  of  Leysin,  however,  was  constructed  so  late 
as  the  year  1 891,  and  opened  a  year  later.  It  has  an  altitude  of 
4750  feet,  and  is  situated  about  nine  hundred  feet  above  the  village. 
It  is  well  protected  from  the  cold  winds,  and  is  surrounded  by  a 
pine-forest.  The  insolation  is  intense,  and,  as  in  Davos,  the  cold 
is  not  felt  by  the  patients  to  the  same  degree  as  in  sanatoria  of 
lower  altitudes.  The  air  is  calm,  and  the  rare  winds  come  mostly 
from  the  south.  From  the  terrace,  "  Liegehalle,"  and  rooms  of 
the  sanatorium  one  has  a  most  beautiful  panorama  of  moun- 
tains, forests,  and  villages.  To  the  right  is  the  '  Uey  of  the 
Rhone,  which  one  can  foilow  from  St.  Maurice  to  Aigle.  The 
building  is  constructed  on  a  large  plateau  (Plateau  de  Feydey), 
and  in  accordance  with  the  rules  of  hygiene  and  comfort.  The 
five  stories  contain  iio  rooms,  of  which  ninety  face  the  south,  the 
others  the  west.  The  majority  of  these  rooms  have  balconies.  All 
the  rooms  are  nearly  ten  feet  high.  The  douche-rooms  and  the 
gymnasium  are  in  the  basement.  In  the  first  story  are  the  dining- 
room,  reception-rooms,  winter-garden,  etc.  The  equipment  of  the 
whole  institution — furniture,  curtains,  carpets,  etc. — have  all  been 
selected  with  a  view  of  easy  and  thorough  disinfection.  Ventilation 
and  heating  is  effected  by  a  .steam  apparatus  under  high  pressure; 
many  of  the  rooms,  however,  have    open  fireplaces  in  addition. 


IMPORTAN-'"   SANATORIA    AND   SPECIAL   HOSPITALS. 


125 


To  the  east  of  the  main  building,  facing  south,  is  a  gallery  nearly 
one  hundred  feet  long,  where  the  patients  take  their  rest  cure. 
Around  the  institution  are  distributed  numerous  sun-boxes  where 
patients  may  rest  from  their  excursions  and  promenades.  There  is 
an  e.xcellent  water-supply,  which  comes  from  the  Tours  d'Ai,  and 
which  is  conveyedlto  the  institution  in  metallic  tubes. 

Leysin  is  better  adapted  to  the  farther  advanced  cases  than 
Davos.  The  institution  was  especially  erected  to  give  the  French- 
speaking  population  a  sanatorium  of  their  own,  the  sanatoria  of 
Canigou,  Durtol,  and  Pau  being  of  more  recent  creation. 


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KiG.  33.— A  Kiosk  at  thk  Lkvsin  Sanatorium. 


When  I  visited  Leysin  I  could  find  but  one  arrangement  which, 
in  the  eyes  of  a  rigid,  modern  phthisio-therapeutist,  would  be  con- 
sidered objectionable.  They  were  building  a  casino,  which,  in  the 
European  interpretation  of  the  word,  means  a  place  of  very  lively 
amusement,  scarcely  conducive  to  the  well-being  of  a  pulmonary 
invalid.  Aside  from  this  the  treatment  and  management  at  Leysin, 
now  in  the  hands  of  Dr.  Exchaquet,  is  the  same  as  in  the  German 
sanatoria,  with  but  very  little  variation.  The  institution  can 
accommodate  130  patients.  The  nearest  railway-station  to  Leysin 
is  Aigle,  on  the  Jura-Simplon  line. 


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126 


PULMONARY  TUBERCULOSIS. 


TONSAASEN  SANATORIUM. 

The  first  sanatorium  established  in  Norway  for  the  exclusive 
treatment  of  pulmonary  tuberculosis  was  founded  in  Tonsaasen  by 
Dr.  Andvord,  in  1887,  under  the  name  of  the  Sanatorium  of  Ton- 
saasen. 

Although  Tonsaasen  has  been  known  as  a  health  resort  since 
1882,  it  was  only  in  1885  that  some  patients,  under  the  direction 
of   Dr.   Andvord, I  remained  all  winter.      To-day  the  sanatorium 


Fig.  34.— Sanatorum  ok  Tonsaaskn. 

enjoys  a  well-merited  reputation  as  an  excellent  institution  for 
the  treatment  of  consumption.  The  establishn'.ent  is  open  all  the 
year,  ant!  the  results  obtained  are  as  good  as  in  the  other  sanatoria 
of  Plurope.  This  beautiful,  mountainous,  and  wooded  region 
of  Norway  seems  to  be  well  adapted  to  the  treatment  of  con- 
sumptives. 

The  climate,  which  was  first  described  by  Moeller,  in  his  book 
"  Les  sanatoria  pour  le  traitement  de  la  Phtisie," '  is  particularly 


'  Moeller.  liruxcllcs,  I.S94. 


IMPORTANT   SANATORIA    AND   SPECIAL   HOSPITALS. 


127 


interesting.  It  resembles  that  of  the  higher  Alpine  regions.  The 
high  mountains  surrounding  Tonsaasen  and  the  vicinity  of  the 
great,  dense  forests  produce  an  almost  uniform  climatic  condition. 
The  summer  is  not  hot;  the  temperature  has  been  known  to 
descend  even  to  the  freezing-point.  The  nights  are  character- 
istically beautiful  and  calm  in  Norway.  While  in  the  winter  the 
thermometer  descends  often  very  low,  the  stillness  of  the  atmos- 
phere makes  even  the  coldest  days  bearable.  Of  course,  the  melt- 
ing of  the  snow  in  spring  causes  some  disagreeable  days.  There 
is  relatively  little  wind,  and  the  lowest  temperature  is  about  twelve 
degrees  below  zero,  Fahrenheit.  The  topographical  situation  of 
the  sanatorium  is  very  picturesque.  It  is  built  on  a  plateau,  from 
which  an  extensive  view  can  be  had  on  one  side  over  the  valley  of 
Bagna,  on  the  other  side  over  the  valley  of  Etna.  A  beautiful  and 
picturesque  route  unites  the  two  valleys.  Many  little  streams  and 
waterfalls  enliven  the  landscape,  and  some  of  the  high  mountains 
are  perpetually  covered  with  snow. 

Tlie  establishment  is  situated  1850  feet  above  the  .sea,  and  is 
composed  of  six  different  buildings.  There  are  large  verandas  in 
front  of  all  the  houses,  where  the  patients  take  their  rest  cure. 
The  largest  of  the  si.x  buildings  contains  the  dining  room,  music- 
and  conversation-rooms.  The  interior  equipment  is  plain,  comfort- 
able, and  in  accordance  with  the  conception  of  modern  hygiene  for 
pulmonary  invalids.  There  is  also  a  hydrotherapeutic  institution, 
where  patients  receive  their  douches  and  where  plain  and  fnedicated 
baths  arc  given.  The  acrotlierapeutics,  as  carried  out  at  Tonsaasen, 
are  particularly  interesting.  Dr.  Andvord  assured  nie  that  he  has 
his  patients  take  the  rest  cure  in  the  open  air,  on  their  chairs,  well 
tucked  up  in  their  furs,  from  seven  to  nine  hours  per  day,  even 
when  the  temperature  is  as  low  as  10°  or  12°  F.  below  zero. 

Recently  the  direction  of  the  sanatorium  has  passed  into  the 
hands  of  Dr.  Soemme.  Tonsaasen,  which  is  a  railway-station,  can 
be  reached  from  Christiania  by  way  of  Randsfjord,  Spirillen,  or 
Mjosen,  or  from  Bergen  by  way  of  Leirdalsoren. 


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128 


PULMONAKY    TUBERCULOSIS. 


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ALLAND  SANATORIUM. 

It  was  in  1883  that  Professor  Ritter  von  Schrutter,  of  the  Vienna 
University,  conceived  the  idea  of  creating  an  institution  for  the 
treatment  of  the  poorer  classes  of  consumptives.  Me  had  it  espe- 
cially in  view  to  relieve  the  crowded  ho.spitals  of  Vienna  from  the 
numerous  consumptive  patients  which  were  distributed  in  their 
wards.  In  1884  he  formed  the  first  committee  for  the  purpose  of 
carrying  out  his  plans;  but  it  was  not  until  1892  that  an  association 
was  formed  for  the  purpose  of  erecting  and  maintaining  a  sanatorium 
for  tuberculous  patients.  An  appeal  to  the  public  was  made,  and, 
with  the  aid  of  many  generous  philanthropists,  a  capital  sufficiently 
large  was  placed  in  the  hands  of  the  building  committee.  A 
beautiful  and  suitable  locality  was  found  in  a  valley  at  a  distance 
of  about  seven  miles  from  Baden,  near  Vienna,  and  not  far  from 
the  little  village  of  Alland,  in  the  VVienerwald.  This  region,  pro- 
tected from  the  north,  the  east,  and  the  west  by  a  mountain  chain, 
open  toward  the  south,  is  particularly  well  adapted  for  a  sanatorium 
for  consumptives.  The  highest  part  of  the  valley  is  about  two 
thousand  feet,  and  the  sanatorium  is  built  at  an  elevation  of  1300 
feet.  The  plan  of  the  sanatorium  was  drawn  by  Professor  Thyer, 
I'f  Gratz.  The  main  building  has  three  stories.  There  is  one 
large  room  35  feet  long,  of  which  all  the  windows  face  south. 
This  forms  the  parlor.  On  each  side  of  this  parlor  are  two  wards, 
one  with  eight  and  the  other  with  four  beds.  On  the  same  floor 
are  also  the  bath-rooms  and  rooms  for  the  nurses.  The  upper 
stories  are  occupied  by  bedrooms,  but  besides  these  each  story  has 
an  inhalation-room  and  a  special  room  for  the  application  of 
douches.  The  recreation- room  and  the  kitchen  are  annexed  to  the 
main  building.  There  are  separate  buildings  for  laboratories  and 
for  performing  autopsies.  The  physician-in-chief  lives  in  a  sepa- 
rate pavilion,  but  his  assistants  have  rooms  in  the  sanatorium. 
Only  patients  are  received  who  come  from  the  hospitals  of  Vienna 
and  are  in  the  primary  stages  of  the  disease.  Every  patient  ad- 
mitted into  the  sanatorium  is  taken  on  a  three  weeks'  trial.  If  he 
improves,  he  is  retained  three  weeks  longer;  if  not,  he  is  sent  back 
to  one  of  the  general  hospitals,  which  means  that  his  case  is  con- 
sidered incurable.  The  patients  are  expected  to  follow  implicitly 
the  rules  and  regulations  of  the  institution  and  the  prescriptions 
of  the   physicians.     The    treatment,   of  course,    is    hygienic    and 


IP! 


IMPORTANT    SANATORIA    AND    SI'liCIAL    HOSI'lTALS.  I  29 


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130 


PUI.MONAKV   TUIIERCULOSIS. 


dietetic — so  vastly  different  from  tliat  employed  in  the  general 
hospitals. 

There  is  a  large  tract  of  ground  belonging  to  the  sanatorium 
where  the  patients  can  enjoy  outdoor  life.  The  .stronger  ones  are 
permitted  to  do  light  work,  such  as  gardering,  etc.  The  sanatorium 
thus  far  can  accommodate  350  patients. 

At  the  head  of  the  enterprise  and  the  society  .'stands  the  ener- 
getic and  distinguished  Professor  von  Schrotter.  The  society  is 
now  in  a  most  flourishing  condition,  and  is  called  "  Verein  zur 
Errichtung  und  Erhaltung  klimatischer  Ileilstiitten."  It  has  now 
more  than  one  thousand  members,  among  them  many  of  the  most 
aristocratic  families  of  Austria,  and  His  Majesty,  the  Emperor,  as  its 
protector.  The  medical  director  of  the  institution  is  Dr.  Ritter  von 
VVeissmayr,  who  is  aided  by  .several  assistant  physicians.  The  suc- 
cess of  this,  the  first  institution  of  its  kind  in  the  Austrian  empire, 
has,  I  am  glad  to  .say,  been  the  cause  of  starting  similar  niovetnents 
in  other  Austrian  cities,  such  as  Baden,  Briick,  etc. 


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ROYAL  HOSPITAL   FOR  CONSUMPTION  AND  DISEASES  OF  THE 

CHEST  AT  VENTNOR. 

To  make  the  title  of  this  institution  complete,  one  should  add 
"  On  the  Separate  Principle,"  and  "  Founded  for  the  Reception  of 
Patients  of  Both  Se.xes  from  all  Parts  of  the  Kingdom."  As  Patron 
we  should  have  to  mention  Her  Gracious  Majesty  the  Queen  ;  and 
as  President,  the  Right  Honorable  the  Earl  of  Roseberry,  K.G.; 
and  as  Treasurer,  Frederick  Charles  Colman,  t"sq.,  J. P.;  and  as 
Chairman  of  the  Board  of  Managers,  .Sir  Richard  li.  Webster, 
G.C.M.G.,  Q.C.,  M.P. 

I  visited  Ventnor  a  few  years  ago  in  the  fall,  and  could  appreci- 
ate why  the  noble  founders  selected  the  Isle  of  Wight  for  a  national 
institution  to  treat  their  consumptive  poor.  Ventnor  is  situated  on 
the  southeastern  coast  of  the  Isle  of  Wight.  The  climate  is  particu- 
larly mild  and  the  atmosphere  very  pure,  and,  owing  to  the  vicinity 
of  the  ocean,  free  from  pathogenic  micro-organisms.  The  highest 
temperature  recorded  during  the  sunmier  was  80°  F.,  and  the  low- 
est during  the  winter  25°  F.  It  was  in  1868  that  Dr.  nill-Has.sal 
began,  with  a  modest  building,  the  institution  which,  up  to  1895, 
had  treated  no  less  than  12,500  patients. 

To-day  the  hospital  comprises  ten  blocks,  providing  accommo- 


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IMPORTANT   SANATORIA    AND   SPECIAL   HOSPITALS. 


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PULMONARY  TUHKRCULOSIS. 


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dation  for  134  men  and  women  patients,  with  a  chapel  in  the  centre 
(connected  by  a  subway).  The  establislinient  is  situated  in  one  of 
the  loveliest  and  most  sheltered  spots  of  the  Undercliff.  The  site 
covers  more  than  twenty  acres,  and  is  about  three-quarters  of  a 
mile  distant  from  Ventnor.  The  hospital  is  erected  upon  the  sepa- 
rate principle — that  is  to  say,  each  patient  has  a  separate  bedroom. 
The  patients  are  distributed  through  the  various  houses,  which  are 
well  sheltered  from  unfavorable  winds,  constructed  upon  sound, 
sanitary  principles,  and  surrounded  by  gardens.  The  patients 
enjoy  the  advantajjes  of  large  sitting-rooms,  a  lovely  landscape  and 
sea-view,  plenty  of  light  and  sea-air,  effective  ventilation  and  good 
drainage,  and  a  regular  temperature — in  short,  the  comforts  of  a 
home,  with  the  medical  appliances  of  a  hospital, 

I  am  sorry  to  say  that  I  have  to  use  the  word  "hospital,"  for 
such  it  is  in  reality,  and  not  a  sanatorium.  There  are  no  verandas, 
no  reclining  chairs  where  the  rest  cure,  or  "  Liegekur  "  of  the  Ger- 
mans, can  be  carried  out.  I  am  convinced  that  if  the  governors  of 
that  splendid  institution  at  Ventnor  would  admit  this  innovation, 
in  addition  to  the  existing  method  of  treatment,  the  results  would 
be  even  better — excellent  as  they  are.  For  1896  Dr.  Coghill  re- 
ports a  mortality  of  4.7  per  cent.;  very  much  improved,  18.5  per 
cent. ;  improved,  60.5  per  ccrft.  The  cases  eligible  for  admission  are 
those  in  an  early  stage  of  pulmonary  tuberculosis,  and  which,  there- 
fore, afford  a  reasonable  expectation  of  marked  alleviation  or  cure. 
Each  person  is  required  to  pay  J^2.50  per  week,  in  part  payment  of 
the  cost  of  maintenance,  etc.,  and  (on  entrance)  a  guarantee  fee  of 
$5.00  to  the  general  superintendent,  which  will  be  returned  on 
leaving  the  hospital,  unless  any  portion  of  it  shall  have  been  for- 
feited for  damage  done. 

The  institution  has  an  annual  expenditure  of  $55,000.  The 
greater  portion  is  raised  by  voluntary  subscription. 

On  my  visit  I  was  most  cordially  received  by  Dr.  Perkins,  who 
was  then  one  of  the  physicians  in  charge.  Among  the  examining 
physicians  we  note  Dr.  Hermann  Weber,  the  celebrated  clima- 
tologist ;  Dr.  Port,  Dr.  Thorowgood,  and  Dr.  Davies,  of  London. 
Besides  these  there  are  three  visiting  and  three  resident  medical 
officers. 


IMPORTANT   SANATORIA   AM)   -SJ'KCIAL    IIOSIMTALS. 


m 


BROMPTON   HOSPITAL. 

Of  the  several  hospitals  for  the  treatment  of  consumption  exist- 
injj  in  the  city  of  London,  I  wisli  to  describe  the  most  interestinjj, 
oldest,  and  larfrest  institution  of  the  kind. 

Hrompton  Hospital  was  founded  in  1S41.  It  is  built  in  the  shape 
of  the  letter  H,  the  depth  of  each  win^  bein<;  190  feet,  and  the  width 
of  the  buildinjj  200  feet.  It  stands  in  a  square  piece  of  ground 
covering  three  acres,  and  faces  the  street.  On  entering  the  lodge- 
gate  there  are  three  broad   drives — one  to  the  central  entrance. 


1-"k;.  .57.— Hcisri  I  al  iok  lUssiMrrivKs,  Driimi'ton  (Ldnikin). 


which  opens  into  a  cheerful  hall  upon  the  first  floor  ;  another  to  the 
east  entrance,  which  leads  to  the  offices  for  the  transaction  of  the 
hospital  business;  and  the  third  to  the  west  entrance,  which  is  for 
the  use  of  the  inmates  and  the  friends  of  the  in-patients  on  visiting- 
days.  The  grounds  are  well  drained,  so  that  the  broad  terrace- 
walks  become  available  for  the  patients  very  soon  after  the  heaviest 
rains. 

The  ground-floor  is  on  a  level  with  the  gardens.  The  west  wiiig 
contains  rooms  for  the  physicians,  resident  medical  officer  and 
clinical  assistants,  and  servants'  hall.  The  east  wing  contains  the 
apartments  of  the  lady  superintendent,  the  linen-room,  store-room, 


M 


J=M.l 


134 


PULMONARY  TUBERCULOSIS. 


Hi ; 


It' 


secretary's  office,  board-room,  and  nurses'  sitting-room.  The 
heating  of  the  hospital  is  effected  by  hot  water  constantly  circu- 
lating in  -irge  pipes  extending  throughout  the  building.  The 
ventilation  is  obtained  by  means  of  extracting-shafts,  consisting  of 
two  lofty  towers  heated  with  steam,  into  which  the  vitiated  air  is 
drawn  through  large  ducts  leading  from  all  the  wards  and  corri- 
dors. There  arc  also  open  fireplaces  in  all  the  wards,  both  on 
account  of  their  cheering  appearance  and  warmth,  and  their  use  as 
ventilating  agents.  The  kitchen  is  on  the  north  side  of  the  central 
basement  corridor,  in  a  separate  building;  it  is  of  large  size  and  is 
fitted  with  all  the  modern  contrivances.  Immediately  adjoining  is 
the  boiler-house,  in  which  are  the  two  boilers  for  supplying  hot 
water  to  the  systems  of  pipes  for  warming  the  building.  It  also 
contains  -i  powerful  steam-boiler,  which  generates  steam  for  heat- 
ini:  the  extracting-coils  in  the  ventilating  towers.  This  boiler 
likewv.e  supplies  steam  to  heat  the  water  in  the  kitchen  and  baths, 
as  also  to  grind  the  coffee  and  to  run  the  dumb-waiter,  which  takes 
up  the  patients'  meals  hot  from  the  kitchen,  as  well  as  other  neces- 
saries ;  also  to  raise  an  elevator  for  conveying  to  and  Trom  the  gal- 
leries those  patients  for  whom  exercise  in  the  grounds  is  desirable. 
This  is  a  great  comfort  for  the  more  feeble,  as  they  are  enabled  to 
enjoy  the  garden  and  fresh  air,  which  otherwise  they  would  not  be 
able  to  enter  by  reason  of  the  fatigue  of  going  up  and  down  the 
stairs. 

The  second  floor  is  devoted  exclusively  to  female  patients,  except 
small  rooms  for  the  chaplain  and  for  each  cf  the  two  head  nurses, 
and  the  two  requisite  pantries,  baths,  and  lavatories.  The  tempera- 
ture is  the  same  in  the  galleries  as  in  the  wards ;  patients  are, 
therefore,  able  to  read  or  work  in  tnese  well-lighted,  roomy  corri- 
dors without  inconvenience  or  exposuie;  or  they  may  walk  there 
when  the  weather  will  not  permit  of  their  going  out;  they  are  also 
provided  with  easy  couches  and  seats  and  movable  tables  for  meals. 
The  gallery  of  the  west  wing  is  named  after  Her  fTajesty,  the 
Patron  of  the  Charity  and  one  of  its  earliest  friends,  and  is  called 
the  "  Victoria  Gallery.  '  The  gallery  of  Ine  east  wing  is  called  the 
"Jenny  Lind  Gallery,"  in  testimony  "^o  the  kindness  of  Madame 
Lind-Goldschmidt,  who  enabled  the  committee  to  conmience  t'  e 
building  of  the  wing,  now  filled  with  grateful  patients.  The  second 
floor  accommodates  lOj  female  patients. 

The  arrangements  on  the  third  floor  are  precisely  the  same  as 


IMPORTANT   SANATORIA   AND   SPECIAL    HOSPITALS. 


135 


those  on  the  second  ;  the  wards  being  occupied  by  male  patients, 
for  whom  tliere  are  107  beds.  The  west  gallery  is  named  after 
H.  R.  H.  the  late  Prince  Consort,  who  laid  the  foundation-stone 
of  the  hospital  in  1844,  and  is  called  the  "  Albert  Gallery."  The 
east  gallery  is  called  after  the  late  "  Sii  Henry  Foulis,  Bart.,"  at 
whose  expense  the  beautiful  chapel  of  the  hospital  was  built.  The 
breadth  of  the  galleries  in  both  floors  is  ten  feet,  and  their  height 
and  that  of  tlie  wards  is  fourteen  feet. 

The  attic-floor  has  comfortable  dormitories  for  the  nurses  and 
servants,  and  in  the  tower  are  the  sleeping-apartments  of  the 
clinical  assistants. 

During  my  visit  to  the  hospital,  under  the  kind  guidance  of  Dr. 
Philip,  who  was  then  resident  medical  officer,  I  was  pleasantly  sur- 
prised by  the  scrupulous  cleanliness  of  everything,  and  the  par- 
ticular care  which  was  exercised  concerning  the  disposal  of  the 
tuberculous  expectoration.  As  a  consequence  of  the  great  care  in 
everything  that  might  possibly  lead  to  a  contamination,  there  has 
never  been  a  case  of  contracted  tuberculosis  among  nurses  or  other 
employees  of  the  hospital.  This  led  Dr.  Williams,  one  of  Bromp- 
ton's  most  distinguished  physicians,  to  deny  the  communicability 
of  pulmonary  tuberculosis.  To  my  regret  there  is  also  in  Brompton 
an  absence  of  arrangements  to  carry  out  the  rest  cure,  such  as  in- 
augurated b}'  Dettweiler  of  Falkenstein. 

Brompton  can  accommodate  321  patients. 

While  the  work  of  the  English  hospitals  for  the  consumptive 
poor  cannot  be  too  highly  estimated,  I  can  but  feel  that  a  custom 
of  granting  privileges  to  governors  and  subscribers  in  regard  to  the 
admission  of  patients  must,  of  necessity,  be  a  detriment  to  im- 
partial charity  and  impartial  selecting  of  the  cases  which  would  be 
most  benefited  by  a  sojourn  in  the  hospital.  It  is  to  be  hoped  that 
there  may  be  a  change  in  this  methofl  of  recruiting  patients,  which 
should'  be  left  entirely  to  the  discretion  of  the  examining  phy- 
sician, aided  by  a  lay  committee  to  investigate  the  financial  situ- 
ation of  the  applicant. 


I 


[ 

i 

■            ■     ,  ^ 

[  1  f 

i;     1 

i !' 


J)l 


136 


PULMONARY    TUBERCULOSIS. 


ilJ 


THE   VICTORIA  HOSPITAL  FOR  CONSUMPTION. 
THE  OUT-DOOR  Department  and  the  Craigleith  Hospital. 

Among  the  many  medical  institutions  which  I  visited  in  Scot- 
land, the  one  which  interested  me  most  was  the  above-named.  It 
was  then  only  in  its  infancy,  but  has  since  grown  steadily,  and  now 
gives  great  promise  for  the  future. 

For  the  interesting  facts  concerning  the  history  of  the  institution 
I  am  indebted  to  Dr.  R.  W.  Philip,  F.R.C.P.Eo.,  in  whose  company 
I  visited  the  institution  in  the  fall  of  1894,  and  to  whom  great  credit 
is  due  for  his  energy  and  devotion  to  the  enterprise. 

In  1887  it  was  proposed  that  the  Local  Jubilee  Memorial  for 
Edinburgh  should  take  the  form  of  a  scheme  for  the  relief  of  con- 
sumptives and  other  sufferers  from  chronic  diseases.  Impressed 
by  th(.  fitness  of  the  suggestion,  a  citizen  waited  on  one  or  two  of 
those  who  were  prominently  associated  with  the  loyal  movement, 
to  urge  the  suitability,  for  the  purpose  in  view,  of  a  hospital  de- 
voted to  the  treatment  of  consumptive  patients.  The  result  of  the 
deliberations  regarding  the  memorial  was  as  unsubstantial  as 
were  the  fears  expressed  regarding  the  success  of  the  hospital. 
There  was  no  local  memorial,  and  nothing  was  done  for  the  tuber- 
culous poor. 

OuT-DooK  Department. 

Disappointed  at  this  turn  of  affairs,  the  promoters  of  the  hos- 
pital movement  commenced  work  on  their  own  account.  A  com- 
mittee was  formed,  and  three  rooms  were  hired  in  13  Bank  Street, 
as  the  nucleus  of  an  out-door  department.  Within  a  kw  weeks 
from  its  opening,  on  the  22d  of  November,  1887,  the  limited 
resources  were  taxed  to  the  uppermost  and  the  waiting-room 
crowded  to  overflowing.  The  ne.xt  .step  was  the  acquisition  of 
larger  premises  at  26  Lauriston  Place.  These  were  adapted  so  as 
to  afford  sufficient  accommodation  for  a  large  out-patient  depart- 
ment, for  which  they  have  been  in  use  since.  They  comprise  two 
large  consulting-rooms,  one  for  new  and  the  other  for  old  patients, 
with  dark-room  fitted  up  for  laryngoscopical  examination, '^ne  large 
and  two  smaller  waiting-rooms,  a  laboratory  for  nu'croscopical  and 
bactei 


logi 


ipen;- 


ipply 


those  of  the  out-patients  who  require  such  help,  and  a  dwelling- 


louse 


for  t! 


e  orncer. 


IMPORTANT   SANATORIA   AND   SPECIAL   HOSPITALS. 


137 


The  out-patient  department  is  worked  in  the  following  way  :  After 
the  patient's  name  and  address  have  been  entered  in  the  books, 
notes  are  made  of  his  condition  ^n  sheets  arranged  for  the  purpose, 
and  a  graphic  report  of  the  physical  signs  recorded  on  outline 
charts.  Careful  inquiry  is  pursued  along  certain  lines,  with  the 
view  of  determining  the  frequency  of  causal  and  concomitant  con- 
ditions. The  larynx  and  expectoration  are  examined  in  the  greater 
proportion  of  the  cases,  with  the  object  of  obtaining  further  evi- 
dence of  tuberculosis.  No  patient  is  seen  on  a  subsequent  occa- 
sion, without  the  record  of  his  condition  and  of  the  treatment 
which  has  been  followed.  A  register  of  the  patient's  weight  is 
made  on  each  visit. 

If  the  condition  be  urgent,  more  particularly  if  there  be  evidence 
of  rapid  progress,  much  pyrexia,  haemoptysis,  or  other  serious 
symptom,  the  patient  is  placed  on  a  list  for  out-door  visiting  by  a 
qualified  medical  officer  of  the  institution,  the  list  being  restricted 
to  cases  of  tubercular  disease. 

In  order  to  disseminate  knowledge  of  the  proper  measures  to  be 
adopted  in  the  treatment  of  tubercular  patients,  printed  instruc- 
tions of  a  simple  character  are  issued  to  all  such  patients  or  their 
friends.  Besides  the  instruction  given  to  the  patients  by  the  phy- 
sicians, and  through  the  printed  directions,  the  dispensary  ofificer, 
who  i:i  an  old  soldier,  trains  many  of  the  younger  subjects  with 
deformed  chests  in  suitable  dumb-bell  and  other  exercises.  Impor- 
tant service  of  a  beneficent  character  has  been  rendered  by  the 
institution  of  a  Samaritan  committee,  in  connection  with  the  out- 
door department.  This  consists  of  some  twenty  ladies,  who,  in 
co-operation  with  the  medical  officer,  undertake  the  home-visiting 
of  the  bedridden  cases  and  the  distribution  to  really  necessitous 
persons  of  invalid  comforts.  This  department  of  the  work  has 
been  of  incalculable  service.  These  labors  have  been  assisted  not 
infrequently  by  the  kiini  ofTices  of  nur.ses  from  the  Queen  Victoria's 
Jubilee  Institute  and  other  organizations. 

The  attendances  at  the  out-door  department  have  been  very 
large,  varying  from  some  thirty  to  as  many  as  eighty-.seven  patients 
on  one  afternoon.  In  addition  to  this,  the  list  of  home-visits  paid 
by  the  medical  officer  has  amounted  to  over  one  hundred  and  forty 
per  niontii. 


il 


>38 


PULMONARY    TUBERCULOSIS. 


i 


II 

1       i 

IIP 

1     :       -4. 

1 

r  ^ 

1 

(           i 

1 

i 

1 

The  Hospital. 

The  svcessive  steps  in  the  elaboration  of  the  out-door  depart- 
ment ser\  '  ;>rove  in  most  forcible  fashion  the  necessity  for  a 
hospital  wht.  elected  number,  at  least,  from  the  mass  of  tuber- 
cular cases  miync  be  received  for  more  special  in-door  treatment. 
The  obtaining  of  this  was  no  easy  task.  Many  conditions  had  to 
be  fulfilled,  and  funds  were  needed.  After  much  consideration  and 
more  than  one  disappointment,  the  acting  committee,  who  took  the 
matter  warmly  in  hand,  were  fortunate  in  obtaining  a  lease  of 
Craigleith  House.  This  is  a  fine  old  property,  little  more  than  a 
mile  to  the  northwest  of  the  west  end  of  Princes  Street,  easily 
accessible  both  by  railway  and  car.  The  substantially  built  man- 
sion-house is  charmingly  situated  in  the  midst  of  some  seven  and 
a  half  acres  of  prettily  disposed  grounds.  It  basks  in  the  sun, 
facing  due  south,  and,  without  being  overshadowed,  is  sheltered  on 
various  sides,  more  particularly  on  the  east  and  northeast,  by  lofty 
trees.  The  property  is  suitably  laid  out  with  walks,  a  high-walled 
garden,  and  park,  which  have  proved  a  great  boon  to  the  patients. 

Entrance  was  obtained  in  March,  1894.  Various  structural 
alterations  were  speedily  undertaken,  so  as  to  adapt  it  for  hospital 
purposes.  These  were  completed  by  the  beginning  of  August, 
when  patients  were  received  at  once. 

The  Victoria  Hospital  for  Consumption,  as  at  present  arranged, 
comprises:  (i)  basement-floor,  containing  kitchen,  scullery,  larder, 
pantries,  and  nurses'  hall ;  (2)  ground-floor,  containing  two  male 
wards  with  three  beds  each,  house-physician's  sitting-room  and 
bedroom,  dispensary,  and  bath-room  and  lavatory  accommodation 
for  male  patients;  (3)  first  floor,  containing  three  large  and  two 
smaller  female  wards  available  for  eight  patients,  lady  superin- 
tendent's sitting-room  and  bedroom,  and  bath-room  and  lavatory 
accommodation  for  female  patients ;  (4)  second  floor,  containing 
bedrooms  for  two  nurses  and  three  maid-servants. 

A  large,  open  courtyard  back  of  the  house  contains  buildings 
which  include  an  observation  ward,  wash-house  and  laundry,  lava- 
tory accommodation  for  the  staff,  disinfecting  chambers,  coal- 
cellars,  etc.  Removed  from  the  hospital,  more  than  one  hundred 
yards  to  the  northwest,  lie  the  mortuary  and  other  offices.  The 
porter's  lodge  is  occupied  by  the  gatekeeper  and  gardener. 

The   house  was  opened  on  the  9th  of  August,  1894,  and  since 


IMPORTANT    SANATORIA    AND   SPECIAL    HOSPITALS. 


■39 


that  date  has  had  its  full  complement  of  patients.  The  Victoria 
Hospital  was  the  first  consumption  hospital  in  Scotland.  Up  to 
the  31st  of  May,  1895,  sixty-two  patients  have  been  under  treat- 
ment, and  the  results  have  been  satisfactory. 

The  climate  of  Scotland  is  certainly  not  one  to  be  considered  as 
ideal  for  the  treatment  of  tuberculous  invalids.  The  good  work 
done  and  the  excellent  results  obtained  by  Dr.  Philip  and  his  asso- 
ciates is  the  best  plea  for  sanatoria  for  the  consumptive  poor  of  all 
climes. 


INSTITUTIONS  FOR  THE  TREATMENT  OF  TUBER- 
CULOUS PATIENTS   IN  THE  UNITED 
STATES   AND  CANADA. 

THE  ADIRONDACK  COTTAGE  SANITARIUM. 

The  Adirondack  Cottage  Sanitarium  is  located  one  mile  to  the 
north  of  Saranac  Lake,  a  village  situated  on  the  northern  part  of 
what  is  known  as  the  Adirondack  Plateau,  in  New  York  State. 
This  region  has  an  elevation  varying  from  fifteen  hundred  to  eigh- 
teen hundred  feet  above  sea-level.  It  is  heavily  wooded  with  pine, 
spruce,  fir,  Canada  balsam,  maple,  birch,  and  beech,  and  has  an 
almost  uniformly  sandy  soil. 

The  plateau  is  studded  with  many  beautiful  lakes  and  mountains, 
the  latter  varying  in  elevation  from  two  thousand  five  hundred  feet  to 
five  thousand  feet  above  sea-level.  The  lakes  are  fed  by  springs  and 
mountain  streams,  which  render  the  water  exceptionally  clear,  and, 
owing  to  the  small  amount  of  dissolved  salts,  it  possesses  but  little 
hardness. 

In  the  heart  of  this  plateau,  with  fifty  to  one  hundred  miles  ot 
forest  in  all  directions,  lies  the  village.  It  is  located  in  a  sheltered 
valley  one  mile  from  the  Lower  Saranac  Lake,  and  is  built  on 
sandy  plains  and  hill-sides  along  the  Saranac  River.  It  is  protected 
from  winds  by  mountains  to  the  north  and  northwest,  while  the 
long  range  to  the  southeast  and  east  of  heavily  wooded  peaks  un- 
questionably influences  the  climate  by  breaking  the  force  from  that 
source,  besides  making  scenery  of  peculiar  beauty. 

The  founder  of  the  sanatorium  has  kindly  sent  me  such  a  good 
descrir 


iptK 


story 


2pr( 


in  full 


The  Adirondack  Cottaee  Sanitarium  was  the  first  institution  in 


«   i  \u 


It 

Ml 


I 


140 


PULMONARY   TUHERCUI.OSIS. 


< 

I 


It) 


IMPORTANT   SANATORIA   AND   SPECIAL    HOSPITALS. 


141 


America  to  attempt  to  cure  incipient  pulmonary  tuberculosis  in 
persons  of  moderate  means.  It  had  its  origin,  fifteen  years  ago, 
in  a  desire  on  the  part  of  its  founder,  Dr.  E.  L.  Trudeau,to  extend 
the  benefits  of  sanatorium  methods  and  an  open-air  life,  spent  under 
good  climatic  influences,  to  working  men  and  women  whose  lives 
are  constantly  sacrificed  on  account  of  their  pecuniary  inability  to 
avail  themselves  of  these  means  of  restoration. 

"  In  1884,  by  personal  appeals,  a  few  thousand  dollars  were  ob- 
tained, with  which  one  small  cottage  and  the  wing  of  the  intended 


5      i 


•im^  s&S^Si^^^^^^^^^    ^'^^^^^HK^^^^l 

■Jj- *wl 

!fi^£l599V^9P^^^^^I^^^^M^^KSS^IK^&v^H^^^^^^^^^^^^^^^^I^^^^^I 

I  i 


Fig.  39.— Main  Blii.ding  ok  the  Adironback  Cottagk  Sanitarium. 


main  building  were  erected.  Each  year  the  work  was  developed 
step  by  step,  and  the  running  expenses  met  principally  through  the 
generous  aid  of  the  guests  at  Paul  Smith's,  Saranac  Inn,  and  other 
hotels  in  the  region,  who  held  annual  fairs  during  the  summer  for 
the  benefit  of  the  institution.  Its  growth  has  been  steady  and 
uninterrupted,  until  a  small  village  consisting  of  twenty-two 
buildings  now  stands  on  the  original  site  where,  fifteen  years  ago, 
the  institution  made  so  humble  a  beginning. 

"  In  order  to  protect  patients  against  the  evils  of  aggregation  the 
cottage  plan  has  been  adopted,  in  spite  of  the  greater  cost  of  build- 


1  , 


14: 


PULMONARY   TUBERCULOSIS. 


)■'& 


\\i 


■:  'I 


i 


ing  and  operating  an  institution  on  tliis  plan,  arid  the  sanitarium  is 
now  composed  of  a  collection  of  eighteen  small  cottages  and  sev- 
eral otiier  structures,  grouped  about  the  main  or  administration 
building. 

"The  cottages  of  the  Adirondack  Cottage  Sanitarium  are  one- 
story  buildings,  which  accommodate  from  two  to  ten  persons,  but 
the  greater  number  have  a  capacity  for  four  or  five  inmates  only, 
and  these  have  been  found  the  most  satisfactory.  Each  patient  has 
his  own  room,  which  opens  into  a  central  sitting-room  in  direct 
communication  with  the  veranda,  on  which  the  out-door  plan  of 
treatment  is  carried  out.  The  partitions  between  the  sleeping- and 
general  sitting-rooms  reach  but  seven  feet  from  the  floor,  an  ar- 
rangement which  gives  the  patient  the  benefit  of  the  entire  air-space 
of  the  cottage,  and  allows  of  its  being  heated  by  a  single  fireplace 
or  stove  located  in  the  general  sitting-room  ;  but  the  walls  which 
separate  the  sleeping-rooms  from  each  other  reach  to  the  ceilings, 
and  are  of  solid  construction.  Good  ventilation  is  insured  by 
transoms  located  over  the  front  veranda. 

"  In  the  main  or  administration  building  are  to  be  found  the 
dining-room,  kitchen,  reception-  and  general  sitting-rooms,  super- 
intendent's and  doctor's  offices,  and  rooms  for  servants  and  nurses, 
while  the  upper  floor  of  the  building  is  devoted  to  large  rooms  for 
a  limited  number  of  patients.  The  library,  recreation  pavilion, 
doctor's  cottage,  chapel,  and  infirmary  are  all  separate  buildings. 
Should  any  patient  in  one  of  the  cottages  become  rapidly  worse  or 
be  taken  suddenly  ill,  he  is  at  once  removed  to  the  infirmary,  where 
every  convenience  for  his  care  and  proper  treatment  is  at  hand. 
The  separation  of  those  who  are  failing  rapidly,  or  are  acutely  sick, 
from  the  comparatively  well,  not  only  furnishes  the  former  with  the 
constant  and  necessary  attention  and  nursing  which  they  require, 
but  withdraws  them  from  the  daily  observation  of  their  more  for- 
tunate cottage-mates,  and  prevents  in  these  the  depression  of  spirits 
which  would  otherwise  occur  from  the  contact  with  the  very  sick. 
The  success  of  this  plan  is  attested  by  the  general  cheerfulness 
of  patients  while  in  the  institution,  who,  contrary  to  what  might 
be  supposed,  are  very  rarely  depressed  in  spirits  at  their  enforced 
exile. 

"The  efficacy  against  infection  which  the  im'i^nse  air-space 
allotted  to  each  patient  by  the  plan  of  construction  affords,  as  well 
as  the  protection  given  by  the  care  taken  of  the  expectoration,  is 


143 


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144 


IMPOUTANT    SANATORIA    AND   SPECIAL    HOSPITALS. 


■45 


shown  by  the  fact  that  the  diistof  tlie  various  buildings  which  have 
been  occupied  by  consumptives  failed  to  infect  guincaj)i^s  when 
injected  subcutaneously  in  these  susceptible  little  animals,  and  that 
during  thirteen  years  not  a  single  employee  has  been  known  to 
have  contracted  tuberculosis. 

"The  treatment  consists  in  the  judicious  application  of  an  open- 


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V\v..  42. 


air  life,  rest,  and  proper  feeding,  with  regulation  of  the  patients' 

habits  and  mode  of  life,  in  a  climate  which  has  shown  a  marked 

tendency  to  improve  the  general  nutrition  of  pulmonary  invalids; 

and  the  methods  do  not  differ  materially  from  those  in  use  in  the 

well-known  foreign  sanatoria,  except   that  much   more  liberty  is 

given  the  patients,  owing  to  the  fact  that  the  great  majority  of  them 
10 


I'  tl 


146 


PULMONARY    TUBERCULOSIS. 


are  in  the  incipient  stage  of  their  disea.se  and  practically  apyretic. 
A  medical  examination  by  one  of  the  examiners  of  the  institution 
in  New  York,  or  by  Dr.  Trudeau  at  Saranac  Lake,  is  strictly  re- 
quired, and  only  patients  in  the  incipient  stages  of  tuberculosis,  or 
suffering  from  the  less  acute  types  of  the  disease,  and  who  cannot 
afford  to  pay  the  usual  prices  at  the  hotels  and  boarding-houses, 
are  admitted. 

"  The  patients  pay  five  dollars  a  week,  and  the  actual  cost  of 
maintenance  is  about  eight  dollars  ..nd  a  quarter  per  patient,  the 
deficiency  being  made  up  by  annual  subscriptions  and  fairs  held  a» 
Paul  Smith's  and  Saranac  Inn,  and  occasionally  in  the  past  at  oth' 
hotels  in  the  region.  There  is  a  small  free-bed  fund,  the  income  oi 
which,  as  well  as  any  subscriptions  received  for  this  purpose,  is 
applied  to  the  free  maintenance  of  deserving  patients  whose  means 
are  exhausted. 

"  Each  year  any  surplus  remaining  over  and  above  the  necessary 
expenditure,  as  well  as  any  subscriptions  which  could  be  procured 
for  this  object,  has  been  put  aside  as  a  nucleus  for  an  endowment 
fund,  and  about  one  hundred  and  thirty  thousand  dollars  of  the 
five  hundred  thousand  necessary  for  this  purpose  have  already 
been  secured.  It  is  to  be  hoped  that  by  subscripticiis  and  bequests 
the  endowment  fund  will  continue  to  grow,  so  that  the  benefits  of 
the  institution  may  be  made  more  generally  available,  and  its 
permanence  ultimately  assured  for  all  time." 

I  have  visited  this  interesting  institution  in  winter  and  in  summer. 
The  results  obtained  in  both  seasons  are  equally  good ;  if  there  is 
any  difference  it  is  always  in  favor  of  the  winter. 

The  year-round  climate  may  be  briefly  described  as  cool  and 
stimulating.  The  average  mean  temperature  for  Saranac  Lake  is 
41.5°  F. ;  that  of  Ne.v  York  City,  for  comparison,  is  51.5°  F.  The 
mean  temperature  by  months  (taken  from  "  U.  S.  Weather  Reports  " 
for  Saranac  Lake)  is  as  follows  : 


Month,  .    .    . 

•  Jnn. 

Fel). 

Mar. 

April 

May 

June 

Mean  Temp., 

.    17° 

«S-4° 

25-7° 

40.1° 

55-1° 

63° 

Year 

Month,  .    .    . 

•  Jiiy 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

41.46 

Me.in  Temp., 

.  66° 

2.3° 

56.8° 

42.7° 

32-7° 

32.2° 

Like  all  elevated  places,  the  range  of  temperature  during  the 
twenty-four  hours  may  be  considerable  at  times.     The  average 


IMPORTANT   SANATORIA    AND   SPECIAL    HOSPITALS. 


147 


mean  daily  range  is  22.5  dej^rees.  This  insures  cool  nights  in 
summer,  though  the  midday  temperature  is  never  so  high  as  in 
the  southwestern  resorts  of  like  elevation  and  greater  dryness. 
Frequent  showers  in  summer  and  snowfalls  in  winter  keep  the  air 
very  pure  and  free  from  dust. 

The  institution  is  and  has  been  since  its  inception  in  charge  of 
Dr.  K.  L.  Trudeau,  whose  services  are  rendered  gratuitously,  as 
are  those  of  Dr.  E.  G.  Janeway,  Dr.  Walter  B.  James,  and  Dr.  H. 
'  P.  Loomis,  who  examine  patients  for  ;ii mission  in  New  Yoik  City. 
There  are  two  resident  physicians,  Dr.  VV.  H.  Jamieson  and  Dr.  J. 
Wilder. 

The  late  Professor  Alfred  L.  Loomis  was  also  deeply  interested 
in  the  welfare  of  this  institution.  He  gave  his  valuable  services 
without  remuneration  as  medical  examiner  from  the  beginning  of 
the  in.stitution  up  to  the  time  of  his  death. 


SANITARIUM  GABRIELS. 

As  a  new  institution  in  the  Adirondack's  we  must  mention 
Sanitarium  Gabriels,  near  Paul  Smith's  Station,  on  the  N.  Y.  C  & 
H.R.  R.  R. 

The  institution,  for  which  Dr.  Seward  Webb  and  Mr.  Paul 
Smith  generously  gave  the  land,  was  formally  opened  on  July  26, 
1897.  The  administration  building  is  at  walking  distance  from 
the  depot.  The  post-office  address  is  Gabriels,  N.  Y.  The 
buildings  stand  on  Sunrise  Mount,  which  is  about  two  thousand 
feet  above  sea-level,  almost  surrounded  by  State  lands,  on  which 
there  are  thousands  of  acres  of  pine,  balsam,  spruce,  etc. 

The  sanatorium  is  on  the  cottage  plan,  in  detached  buildings. 
The  architect  was  the  lion.  I.  G.  Perry,  of  Albany.  The  cottages 
are  of  hard  wood,  so  as  to  permit  of  a  thorough  disinfection  as 
often  as  may  be  necessary.  The  "  Sun  Room  "  in  the  new  in- 
firmary building  is  the  gift  of  ex-Governor  Morton,  and  is  called 
the  "  Anna  L.  Morton  Room."  A  special  feature  of  the  buildings 
is  the  facility  for  heating  and  ventilating  them.  They  are  heated 
by  indirect  radiation  from  a  central  plant.  The  boiler-house  is 
located  about  eight  hundred  feet  from  the  main  building,  as  pro- 
tection against  fire  and  to  prevent  the  patients  being  disturbed  by 
the  dust  and  noise  of  the  machinery.  The  pure  air  from  without 
is  forced  through  a  shaft  into  the  buildings,  and  heated  on  its  way 


^a 


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148 


PULMONARY   TUBERCULOSIS. 


by  radiating  pipes.  One  breathes  the  same  pure  atmosphere  as 
whe  1  out-of-doors.  The  system  is  so  nearly  perfect  that  the  air 
can  be  changed  throughout  the  buildings  every  five  minutes.  The 
quality  and  abundance  of  the  water-supply  are  remarkable  in  the 
Adirondacks.  The  analysis  proves  the  water  a  perfectly  pure 
spring,  and  yet  as  soft  a«!  r.'in  for  bathing,  etc.  The  institution  is 
supplied  with  complete  installations  for  hydrotherapeutic  applica- 
tions, or  the  regulations  1  desire  to  copy  the  following  from  the 
lecent  announcement: 

"  Only  those  who  are  in  the  first  stages  of  consumption  or  con- 
valescing from  other  pulmonary  diseases  are  admitted  as  patients. 


I"ic;.  .(.1.— Sanitauum  Gahkikls. 

"  Persons  from  a  distance  making  application  should  be  exam- 
ined by  one  of  the  consulting  physicians,  and  ha/e  a  written  cer- 
tificate from  him. 

"  Medical  attendance  is  free.  The  charge  per  week  is  from  seven 
to  twelve  dollars,  according  to  location  of  room.  Washing  and 
medicine  form  an  additional  charge.  Patients  requiring  attendance 
in  rooms  will  be  charged  extra. 

"  The  plan  of  the  sanatorium  is  such  that  it  will  reach  both  rich 
and  poor ;  elegant  rooms,  careful  nursing,  every  comfort  and  luxury 
will  be  afforded  the  one  at  a  moderate  price,  and,  as  the  Sisters  re- 
ceive no  personal  remuneration,  the  money  given  for  this  purpose 
will  be  expended  on  the  other.  The  good  and  charitable  have  already 


IMPORTANT   SANATORIA   AND   SPECIAL    HOSPITALS. 


149 


come  forward  to  assist  in  this  noble  work,  but  much  remains  to  be 
done.  The  Sisters  have  built  well  and  substantially,  trusting  Provi- 
dence. Already  over  sixty  thousand  dollars  have  been  spent  on 
the  institution  ;  but  the  bulk  of  this  sum  has  been  expendet".  on  the 
drainage  and  water-supply.  About  seventy  patients  can  be  accom- 
modated." 

At  my  visit  last  year  there  was  no  house-phj'sician  yet.  But  I 
have  since  received  a  letter  from  the  Sister  Superior  stating  that 
Dr.  J.  C.  Lamb  is  now  the  house-physician  of  the  institution. 


^OOMIS  SANITARIUM  FOR  CONSUMPTIVES. 

Liberty,  in  Sullivan  County,  in  the  State  of  New  York,  was  con- 
sidered by  the  late  Dr.  Alfred  L.  Looniis  as  an  ideal  situation  for 
a  sanatorium  where  tuberculous  patients,  after  a  few  hours'  journey 
from  New  York,  would  find  themselves  2200  feet  above  the  sea- 
level,  in  an  air  similar  to  that  of  Colorado  and  the  Adirondacks. 

In  the  winter  of  1894  a  meeting  of  the  Woman's  Auxiliary  of 
the  Hospital  Saturday  and  Sunday  v\ssociation  took  place  at  the 
house  of  Mrs.  Richard  Irvin,  who,  having  Dr.  Loomis's  idea  in 
mind,  determined  to  win  an  interest  in  it  by  telling  of  a  young  girl 
who  was  dying  of  consumption  in  an  inner  tenement,  and  for  whom 
she  had  tried  in  vain  to  gain  admission  to  a  hospital. 

The  urgent  need  for  a  hospital  for  consumptives  was  so  im- 
pressed upon  the  audience  that  at  th"  close  of  the  meeting  a 
woman  present  offered  $1000  toward  the  opening  of  such  an  insti- 
tution. 

From  this  beginning  the  work  gradually  developed.  The  rent- 
ing of  a  small  house  at  230  West  Thirty-eighth  Street  was  soon 
followed  by  the  purchase  of  193  acres  of  land  not  far  from  Liberty, 
where  it  was  hoped  in  the  near  future  to  build  a  sanatorium  for 
the  treatment  of  incipient  phthisis,  on  the  lines  so  much  desired  by 
Dr.  Loomis. 

Then  came  the  death  of  this  distinguished  and  beloved  physi- 
cian, and,  following  it,  the  noble  gift  of  the  sanatorium  as  a  me- 
morial of  him  by  Mr.  J.  Pierpont  Morgan. 

The  sanatorium  was  incorporated  on  January  24,  1896,  a.id 
opened  to  the  public  on  June  1st.  It  is  situated  two  miles  west 
of  Liberty,  and  stands  on  the  southern  slope  of  a  hill  crowned 
with  forests  and  girt  by  a  caverned  ledge.     It  forms  a  picture  full 


V 


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ISO 


PULMONARY   TUBERCULOSIS. 


li'  ' 


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o 
J 
I 


IMPORTANT  SANATORIA   AND   SPECIAL   HOSPITALS. 


151 


of  beauty,  sunshine,  and  refinement.  The  ample  grounds,  attract- 
ively laid  out  with  graveled  walks  and  drives,  command  an  exten- 
sive and  uninterrupted  view  of  the  surrounding  country  for  many 
miles. 

The  Loomis  Memorial  and  Administration  Building,  built  of 
roughly  hewn  graystone  and  timber,  designed  by  Mr.  Bruce  Price, 
stands  on  a  plateai'  on  the  highest  part  of  the  grounds,  '^d  Icoks 
over  a  rarely  beautiful  expanse  of  mountain  and  vatley.  The 
dimensions  are  190  feet  by  60  feet.  It  is  three  stories  high,  and 
contains  reception-room,  library,  dining-room,  offices,  drug-room, 
butler's  pantry,  kitchen,  store-room,  and  laundry  on  the  first  floor. 
The  second  floor  has  a  solarium,  four  emergency  wards,  laboratory, 
nurses'  rooms,  baths  and  closets,  sleeping-rooms  for  house  staff, 
and  guest-rooms.  On  the  third  floor  arc  servants'  quarters  and 
store-rooms.  All  the  charm  of  modern  decoration  and  furnishing 
is  shown  in  the  interior,  and  ever-  modern  appliance  equips  the 
house.  Over  the  mantel  in  the  libiai}  a  bronze  tablet,  with  palm- 
and  laurel-branch  on  either  side,  bears  the  following  inscription  ; 
"  This  building  is  erected  in  loving  memor\  <  ♦  Alfred  L.  Loomis, 
M.D.  To  be  used  as  a  Sanitarium  for  the  treatment  of  Phtl  isis. 
1831-1895." 

Grouped  around  the  main  building,  within  a  few  hundred  yards 
of  it,  are  a  casino  and  eight  cottages.  The  casino,  given  '>>  Mrs. 
George  Lewis  in  memory  of  her  husband,  is  a  two-storj  luilding 
of  stone  and  wood,  fifty  by  sixty  feet,  with  a  huge  fireplace  and 
the  attractions  of  a  billiard-table,  organ,  piano,  games,  etc.,  for  the 
amusement  of  the  patients. 

The  sanatorium  can  accommodate  about  eighty  patients. 

Each  building  is  heated  by  its  own  hot-water  plant,  and  lighted 
from  a  central  dynamo.  There  is  a  reservoir  situated  above  the 
highest  point  of  the  sanatorium,  into  which  water  is  pumped  from 
a  mountain  spring,  thus  insuring  a  pure  water-supply. 

The  staff  consists  of  Dr.  Stubbert  (the  physician-in-charge),  and 
a  house-physician.  Dr.  Walter  V.  Chappel,  of  New  York,  is  the 
laryngologist  of  the  institution. 

There  is  a  laboratory,  furnished  with  all  the  necessary  appa- 
ratus for  bacteriological  and  experimental  work  ;  also  a  powerful 
"  X-ray"  apparatus  and  well-equipped  throat-room. 

The  general  idea  of  the  sanatorium  is  that  known  as  the  cottage 
plan  :  patients  are  grouped  in  cottages  short  distances  from  the 


^m 


152 


PULMONARY   TUBERCULOSIS. 


main  building,  and,  except  in  rainy  weather,  have  daily  exercise 
in  walking  back  and  forth  for  meals,  and  for  the  amusements  at 
the  casino. 

The  object  of  this  sanatorium  is  to  help  persons  in  the  incipient 
stages  of  phthisis  to  recover  their  health,  who  by  reason  of  limited 
means  are  unable  to  go  to  more  expensive  resorts  or  to  travel 
greater  distances.  Only  those  will  be  admitted  who  are  in  the 
early  stages  of  consumption,  and  to  whom  a  residence  for  a  number 
of  months  in  the  sanatorium  promises  either  a  complete  cure  or 
such  an  improved  condition  that  they  can  return  to  their  homes 
and  be  able  to  carry  on  their  work. 


I'Ki.  4,'i.— A  CoTi'Ac.i;,  I.ooMis  Samiarium  ai    I.iiikkty. 

As  for  the  financial  basis  of  the  institution,  Dr.  Stubbert  said  to 
me,  in  a  recent  letter:  "  It  is  not  a  charitable  stitution,  neither  is 
it  a  money-making  one ;  we  aim  to  give  the  i)atients  the  very  best 
of  everything  in  the  way  of  buildings,  food,  nn  icai  attendance,  and 
comforts  of  all  kinds  that  can  be  expected — that  is,  we  plan  to  give 
them  everything  that  they  could  obtain  from  money-making  sana- 
toria charging  $25,00  to  $50.00  a  week.  Our  rates  are  312.00, 
$15.00,  and  $20.00  a  week;  there  are  a  few  beds  on  which  we 
hope  in  the  future  endowments  will  be  placed,  whereby  each 
patient  will  receive  from  the  beneficiary  fund  $5.00  a  week  toward 
his  expenses.     You  will  therefore  see  that  the  aim  of  this  insti- 


IMPORTANT   SANATORIA   AND   SPECIAL   HOSPITALS. 


153 


tution  is  to  reach  a  class  of  patients,  first,  who  are  able  to  pay  their 
way  absolutely ;  second,  who  are  of  good  connection  and  person- 
ality, and  yet  who  need  a  certain  amount  of  aid — in  other  words, 
the  sanatorium  is  supposed  to  receive  refined  people.  To  my 
rnind,  this  is  even  a  greater  charity  than  that  which  reaches  out  to 
only  the  poorer  elements  of  our  cities." 

Before  patients  can  be  admitted  they  must  be  examined  by  either 
Dr.  H.  P.  Loomis,  Dr.  Charles  E.  Quimby,  or  Dr.  A.  A.  Smith, 
of  New  York ;  or  by  Dr.  J.  E.  Stubbert,  at  the  sanatorium  ;  or  by 
some  other  member  of  the  medical  board. 

Liberty  is  located  on  the  main  line  of  the  New  York,  Ontario 


I 


I'li;.  ,(6.— A  Cottai;k  I)kauini;-room  at  thk  I.oomis  Sanitaku m. 


&  Western  Railway,  1 19  miles  from  New  York,  and  has  an  ele- 
vation of  from  sixteen  hundred  to  eighteen  hundred  feet  above  tide 
— the  greatest  elevation  reached  on  this  railroad  between  New 
York  and  the  Great  Lakes.  The  atmosphere  at  Liberty  is  always 
invigorating;  the  nights  are  cool  in  summer,  and  the  winds  make 
even  the  hot  days  bearable.  The  winters  are  cold;  the  ground 
freezes  up  in  November  and  remains  so  until  late  in  the  spring. 
The  intense  cold  is  less  felt  at  Liberty  than  in  the  lowlands,  and 
the  patients,  as  a  rule,  enjoy  the  out-door  life  at  Liberty  as  much 
in  winter  as  in  summer. 

The  last  semi-annual  report,  dated  May  i,  1898,  which  Dr.  Stub- 
bert had  the  courtesy  to  send  me,  shows  the  following  remarkable 


1 

1 

5  r  2^ 

1 

(■' . 

•■ 

., 

f' 

I 

154 


PULMONARY   TUBERCULOSIS. 


results  obtained  in  the  Loomis  Sanitarium  :  "  During  the  past  six 
months  i8  per  cent,  had  lost  their  bacilli.  During  the  first  year 
13  per  cent,  of  the  patients  discharged  were  apparently  cured, 
while  during  the  past  six  months  23  per  cent,  of  those  discharged 
were  apparently  cured,  and  70  per  cent,  of  those  discharged  were 
either  cured,  had  their  disease  arrested,  or  were  so  much  improved 
as  to  be  able  to  return  to  their  work.  Of  the  patients  discharged 
after  a  residence  of  three  months  or  less  at  the  sanatorium  17  per 
cent,  were  apparently  cured,  while  of  those  who  remained  more 
than  three  months  26  per  cent,  were  cured." 

The  treatment  in  vogue  at  Liberty  is  the  hygienic  and  dietetic 


Fig.  47.— a  Bedroom  at  the  Loomis  Sanitarium. 

method,  but  Dr.  Stubbert  has  also  used  recently  the  U.  S.  Govern- 
ment serum  (of  de  Schweinitz)  in  a  number  of  cases,  and  has  noted 
a  fair  number  of  improvements  under  its  administration.  Dr. 
Stubbert  believes  more  in  exercise  than  most  European  and  Amer- 
ican phthisio-therapeutists.  As  a  rule,  he  allows  all  patients  whose 
evening  temperature  does  not  reach  100°  F.  to  walk  moderately, 
and  if  their  temperature  is  not  above  99°  F.  no  restrictions  at  all 
are  placed  upon  them  in  this  respect,  but  they  are  allowed  to 
gradually  accustom  themselves  to  pedestrian  tours  extending  over 
from  two  to  ten  miles  daily.  He  assures  me,  and  also  states  in  his 
recent  report,  that  he  has  never  seen  any  untoward  results  from 


IMPORTANT  SANATORIA   AND   SPECIAL   HOSPITALS. 


155 


this  exertion  on  the  part  of  the  patients,  and  he  considers  it  a  mis- 
take to  encourage  any  such  cases  to  take  the  rest  cure. 

An  interesting  innovation  has  been  inaugurated  at  Liberty  by 
Dr.  Stubbert  by  creating  a  nurses'  training  school.  The  course 
being  two  years,  they  receive  a  thorough  training  in  the  sanitary 
work  of  a  sanatorium,  and  are  lectured  to  twice  a  week  by  the 
difterent  members  of  the  medical  staff.  To  nurse  a  consumptive  is 
not  always  an  easy  task,  and  to  train  nurses  in  this  special  art  is  an 
idea  for  which  Dr.  Stubbert  is  to  be  congratulated. 

The  Loomis  Sanitarium  has  also  a  city  branch  for  consumptives, 
where  the  incurable  cases  are  admitted.  It  is  located  at  104  and 
106  West  Forty-ninth  Street.  Attached  to  it  is  also  an  out-door 
dispensary.  One  of  the  houses  is  devoted  absolutely  to  charity 
patients,  and  the  other  to  those  who  are  able  to  pay  for  their  board 
(seven  to  ten  dollars  a  week). 


MONTEFIORE   HOME  COUNTRY   SANITARIUM. 

At  Bedford  Station,  Westchester  County,  near  New  York,  at  an 
elevation  of  about  four  hundred  and  fifty  feet,  there  has  existed, 
since  September,  1897,  a  little  sanatorium  which  has  grown  and 
promises  to  become  an  important  institution  for  the  treatment  of 
the  consumptive  poor.  It  constitutes  an  annex  to  the  Montefiore 
Home  for  Chronic  Invalids  situated  in  the  city  of  New  York. 

The  institution  comprises  130  acres.  It  gets  its  water-supply 
from  an  artesian  well  400  feet  deep,  and  has  a  storage  tank  of  32,000 
gallons  of  pure,  wholesome  water.  There  is  a  farm  attached  to  the 
institution,  which  supplies  eggs,  good  milk,  fresh  fruit,  and  vege- 
tables. The  institution  was  opened  with  ten  patients,  but  the  need 
for  additional  accommodation  made  itself  felt,  and  a  pavilion  with 
twenty-four  beds  was  erected  and  opened  in  May,  ',8gS. 

The  first  annual  report  shows  that  57  patients  had  been  treated, 
of  whom  5  were  cured,  8  left  in  an  improved  condition,  15  were 
transferred  to  the  Montefiore  Home  at  One  Hundred  and  Thirty- 
eighth  Street  and  Grand  Boulevard,  New  York,  as  their  advanced 
condition  of  phthisis  became  detrimental  to  the  surrounding  in- 
cipient cases;  29  cases  remained  in  the  .sanatorium  at  the  time 
the  report  was  finished. 

The  sanatorium  had  its  inception  through  the  generous  gifts  ot 
Messrs.  Bloomingdale  and  Schiff,  and  is  exclusively  for  the  con- 


n 


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156 


PULMONARY   TUBERCULOSIS. 


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IMPORTANT   SANATORIA   AND   SPECIAL   HOSPITALS. 


157 


surpptive  poor,  which  are  selected  from  the  applicants  for  admission 
to  the  Montefiore  Home  for  Chronic  Invalids.  The  house-physi- 
cian of  the  institution  is  Dr.  Herbert;  the  medical  director,  Dr.  J. 
Fraenkel.  It  is  the  plan  of  the  founders  to  add  to  the  existing 
buildings  some  smaller  cottages  with  separate  rooms,  more  suitable 
for  the  care  of  tuberculous  invalids  than  is  the  original  large  pavil- 
ion, which  consists  only  of  a  large  dormitory.  I  reproduce  here  a 
photograph  of  the  latter,  showing  tlie  neatness  with  which  the  insti- 
tution is  kept.  For  the  benefit,  however,  of  all  those  desiring  to 
build  sanatoria  for  consumptives,  I  must  criticize  the  arrangement 
whereby  twenty-four  patients  congregate  at  night  in  one  large  hall. 
To  me  it  seems  to  be  an  utter  impossibility  to  assure  a  good  night's 
repose  to  these  invalids,  as  among  such  a  large  number  coughing 
will  be  heard  mo:e  or  less  all  the  time,  and  thus  they  will  disturb 
each  other. 


o 
u 


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X 


THE   PASTEUR  SANATORIUM. 

Pasteur  Sanatorium  is  the  name  given  by  Dr.  Paul  Gibier,  Direc- 
tor of  the  Pasteur  Institute  of  New  York,  to  the  sanatorium  for  the 
treatment  of  tuberculous  patients  at  Suffern.  In  selecting  this 
name  Dr.  Gibier  desired  to  honor  the  memory  of  his  celebrated 
teacher. 

Suffern  is  a  little  village  and  station  on  the  P>ie  Railroad,  a  short 
distance  (about  one  hour  by  rail)  from  New  York  City.  The  sana- 
torium is  situated  at  the  foot  of  the  Ramapo  Mountains,  in  Rock- 
land County,  N.  Y.,  at  an  elevation  of  500  feet  above  sea-level.  The 
laboratories  of  the  Pasteur  Institute  and  the  model  farm  belonging 
to  Dr.  Gibier  are  also  on  the  same  property,  which  comprises 
about  two  hundred  and  fifty  acres. 

The  sanatorium  stands  on  higher  ground  than  the  other  build- 
ings, and  tlie  structure  is  built  according  to  the  best  sanitary  prin- 
ciples, and  in  compliance  with  the  requirements  of  modern  phthisio- 
therapy.  It  has  a  south  and  southwestern  exposure,  and  is  in  the 
immediate  vicinity  of  a  grove  of  pine,  chestnut,  maple,  and  oak- 
trees.  There  are  verandas  and  balconies  for  the  rest  cure  in  the 
open  air.  The  principal  veranda  is  twelve  feet  above  the  ground, 
in  front  of  the  second  story,  and  can  be  entirely  closed  by  glass 
and  transformed  into  a  solarium  in  too  cold  and  windy  days. 

The  ground-floor  is  used  for  liydiotherapy  and  for  bacteriologi- 
cal and  "X-ray"  work.      On  the  main-floor  are  the  diniug-room, 


II 


158 


PULMONARY   TUnERCULOSIS. 


lU        m 


IMPORTANT   SANATORIA    AND   SPECIAL   HOSPITAI^. 


>59 


parlors,  library,  billiard-room,  music-room,  etc.  The  kitchen,  the 
laundry,  the  servants'  rooms,  and  the  machinery  arc  in  an  annex, 
connected  by  a  corridor.  The  sanatorium  is  provided  with  fresh 
vegetables  and  excellent  milk  from  the  farm.  The  cows  are  tested 
at  regular  intervals  by  a  competent  veterinary  surgeon. 

The  woods  surrounding  the  sanatorium  and  the  Spitzberg  Moun- 
tain near  by  offer  pleasant  e.xcursions  to  the  patients.  The  cottage 
of  the  medical  director  is  about  one  vhousand  feet  distant  from  the 
sanatorium,  with  which  it  is  connected  by  telephone.  The  estab- 
lishment is  heated  by  hot  water  and  lighted  by  electricity.  A  house- 
physician  resides  in  the  sanatorium. 

The  climate  at  Suffern  is  similar  to  that  of  New  York,  but  the 
atmosphere  is  very  much  purer,  and  in  summer  it  is  less  hot.  The 
treatment  in  the  sanatorium  is  the  hygienic  and  dietetic  method  as 
prescribed  by  T^rehmer,  Dettweiler,  and  their  followers.  For  the 
time  being  there  is  accommodation  for  about  thirty  patients,  A 
number  of  beds,  however,  are  destined  by  the  founder  of  the  sana- 
torium for  the  reception  and  free  treatment  of  poor  tuberculous 
physicians  of  whatever  nationality,  school,  or  religion.  The  price 
for  room,  board,  and  medical  attendance  varies,  according  to  the 
location  of  the  rooms,  from  twelve  to  twenty-five  dollars  a  week. 
An  additional  pavilion  is  projected.  The  accompanying  cut  gives 
a  general  idea  of  the  external  appearance  of  the  establishment. 


SETON   HOSPITAL. 

At  Spuyten  Duyvil,  within  the  precincts  of  Greater  New  York, 
there  was  erected,  in  1894,  a  majestic  building  for  the  care  and  treat- 
ment of  the  poorer  classes  of  consumptives.  The  building  faces 
Spuyten  Duyvil  Parkway,  and  can  be  reached  within  twenty  five 
minutes  from  the  Grand  Central  Station.  It  stands  on  high  ground 
(250  feet  above  the  level  of  the  sea),  and  from  its  balconies  one  has 
a  fine  view  over  the  Hudson.  The  wards  of  the  institution  are 
large,  airy,  and  cheerful.  Each  has  a  capacity  of  twelve  beds. 
There  is  a  system  of  fans  and  ventilators,  maintaining  an  even  tem- 
perature in  the  building.  One  of  the  chief  attractions  of  the  insti- 
tution is  a  large  solarium  filled  with  growing-plants,  where  in  cold 
and  stormy  weather  the  patients  delight  to  congregate. 

The  institution  is  under  the  charge  of  the  Sisters  of  Charity, 
and  can  accouimodate   160  patients.     The  patients  pay  for  their 


'A 


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1 60 


PULMONARY   TUHKKCUI.OSIS. 


board  only  (five  dollars  a  week).  With  the  be<jinniii^  of  the  year 
1 898,  the  Seton  Hospital  took  char^je  of  tlie  C(  nsuniptive  poor  of  the 
city  of  New  York,  selected  by  the  Hoard  of  Health,  for  which  they 
receive  one  dollar  a  day  for  each  patient.  The  house-physician 
is  Dr.  Pafitird,  and  Drs.  Jackson  and  Shrady  are  visitin<j  physicians. 


I 

I 


ST.  JOSEPH   HOSPITAL   FOR  CONSUMPTIVES. 

This  institution,  one  of  the  most  important  of  its  kind  in  the  city 
of  New  York,  covers  the  entire  block  situated  between  St.  Annis 
and  Brook  Avenues  and  One  Hundred  and  Forty-third  and  One 
Hundred  and  Forty-fourth  Streets.  This  hospital  is  owned  and 
conducted  by  the  Roman  Catholic  order  of  the  Sisters  of  St.  Francis. 
It  was  opened  in  1882,  as  the  Sisters  found  it  impracticable  to  care 
for  consumptives  in  their  general  hospital  in  Fast  Fifth  Street.  The 
original  building  was  situated  in  One  Hundred  and  Ninth  Street, 
and  the  present  edifice  was  not  occupied  before  January,  1889. 
There  is  a  nice  garden  attached  to  the  grounds.  The  main  building 
is  a  four-story  structure,  facing  south,  with  east  and  west  wings.  It 
is  lighted  by  gas  and  heated  by  hot-air  furnaces.  The  ground-floor 
is  divided  into  waiting-rooms,  sitting  rooms,  offices,  examining- 
rooms,  small  wards,  etc.  The  three  upper  stories  are  each  divided 
into  five  large  wards,  five  small  wards,  and  a  few  single  rooms. 
The  chapel  occupies  a  separate  extension.  In  the  rear  of  the  main 
building,  but  separated  from  it,  is  a  house  devoted  to  the  use  of 
incipient  and  arrested  cases  of  consumption.  Farther  in  the  rear 
are  the  power-house,  the  stable,  workshop,  etc. ;  and  in  the  extreme 
northwest  corner  the  mortuary,  with  separate  entrance  from  the 
street. 

The  hospital  contains  350  beds,  more  than  300  of  which  are 
entirely  free  and  constantly  occupied  by  the  sick  poor,  who  are 
admitted  irrespective  of  nationality,  race,  or  religion.  Patients  in 
all  stages  of  the  disease  are  received  and  many  beds  given  up  to 
those  far  advanced  in  consumption,  for  whom  only  relief  from 
suffering  during  their  last  days  is  expected.  An  average  of  1500 
patients  is  treated  each  year.  Apart  from  the  individual  good 
which  these  consumptives  may  derive  from  hospital  care  and  in- 
struction in  the  disposal  of  sputa,  etc.,  an  incalculable  benefit  is 
conferred  upon  the  public  at  large,  as  well  as  upon  their  friends 
and  families,  by  removing  the  invalids  to  a  place  where  they  cease 


the 


l62 


PULMONARY  TUBERCULOSIS. 


to  be  centres  of  infection,  and  where  they  no  longer  hamper  the 
wage-earning  capacity  of  the  remaining  members  of  their  famih'es. 

The  institution  is  not  endowed.  I',  is  supported  by  the  voluntary 
contributions  of  its  friends  and  a  benevolent  public. 

The  physician-in-chief  of  the  St.  Joseph  Hospital  is  Dr.  Chas. 
M.  Caaldwell.  The  consulting  physicians  are  Drs.  John  Doming 
and  F.  E.  Miller.  Drs.  Starke,  Morrissey,  Holmes,  Burke,  T.  J. 
Larkin,  Butler,  Wollner,  Howley,  Smith,  Murray,  Dunphy,  Spence, 
J.  H.  Larkin,  Sutorius,  Loughran,  Schwerd,  Skeel,  J.  P.  Burke,  and 
Heuel  are  visiting  physicians  and  surgeons. 


n     m 


THE  HOSPITAL  FOR  DISEASES  OF  THE  LUNGS  AT  CHESTNUT 
HILL,  PHILADELPHIA. 

Under  the  ^auspices  of  the  Philadelphia  Protestant  Episcopal 
Mission  there  flourish  several  philanthropical  institutions.  Among 
these  there  are  two  consecrated  to  the  care  of  the  consumptive 
poor.  One  is  the  "  Hospital  for  Diseases  of  the  Lungs  "  for  female 
patients,  situated  at  Chestnut  Hill ;  the  other  is  the  "  House  of 
Mercy"  for  male  consumptives,  at  411  Spruce  Street,  with  a 
capacity  of  twelve  bed.s.  Concerning  the  latter,  I  only  wish  to 
give  a  report  of  the  work  done  during  the  year  1897.  Forty-three 
patients  were  received  during  the  year ;  1 1  were  discharged 
improved;  14  were  discharged  not  improved;  7  died,  and  n 
remained  under  care.  When  one  considers  that  this  institution 
admits  consumptives  at  any  stage  of  the  disease,  the  good  work 
done,  though  on  a  small  scale,  speaks  for  itself. 

Of  far  more  importance,  and  on  a  larger  scale,  is  the  work  done 
at  the  Chestnut  Hill  institution,  which  can  accommodate  eighty 
patients.  I  visited  this  hospital'  some  time  ago  under  the  kind 
guidance  of  Dr.  J.  Solis-Cohen,and  was  charmed  with  its  situation. 
It  has  an  elevation  of  500  feet  above  tide-water,  and  is  at  a  distance 
of  twelve  miles  from  the  City  Hall  of  Philadelphia.  The  institu- 
tion consists  of  a  series  of  buildings  and  cottages  with  sun-parlors, 
etc.,  of  one  of  which  I  give  an  illustration.  The  hygienic  arrange- 
ment is  most  excellent.  With  few  exce|)tions,  every  patient  has  a 
room  for  herself.  The  central  administration  building  contains 
parlors,  doctors'  offices,  diug-room,  dining-room,  kitchen,  and 
dormitories  for  the  staff  and  help.  The  cottages  are  connected 
with  the  main  building  by  covered  passage-ways.     The  heating  is 


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164 


PULMONARY   TUBERCULOSIS. 


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done  by  indirect  radiation,  the  boiler-house  being  situated  300  feet 
from  the  nearest  cottage. 

For  both  institutions  (the  "  House  of  Mercy  "  and  the  "  Chestnut 
Hill  Hospital")  the  conditions  for  admission  are  alike.  The 
patients  must  be  suffering  with  disease  of  the  lungs  in  some  form, 
and  the  question  of  money  does  not  enter  into  the  admission  at  all. 
Patients  of  any  religious  denomination  are  received. 

The  treatment  in  the  institution  is  hygienic,  dietetic,  and  symp- 
tomatic as  carried  out  in  German  sanatoria,  though  galleries  with 
reclining  chairs  for  the  rest  cure  proper  did  not  exist  at  the  time 
of  my  visit.  There  is  a  special  department  for  diseases  of  the 
throat  under  the  charge  of  Dr.  A.  W.  Watson.  The  visiting 
physicians  are  Drs.  J.  Solis-Cohen,  F.  P.  Henry,  E.  W.  Watson, 
and  W.  M.  Angney.  Dr.  Robert  L.  Pittfield  is  the  bacteriologist 
of  the  institution.  The  house-physician  is  Miss  Anna  L.  Bacon, 
M.D.     The  superintendent  is  the  Rev.  L.  Duhring. 

One  hundred  and  twenty-one  patients  have  been  t-eated  during 
the  year,  of  which  14  were  cured,  18  improved,  12  unimproved, 
and  21  died.  Here,  too,  even  advanced  cases  are  admitted,  and 
the  reported  results  show  what  can  be  accomplished  in  our  Eastern 
climates  by  persistent  hygienic  and  dietetic  care,  combined  with 
open-air  treatment. 


,li. 


RUSH  HOSPITAL  FOR  CONSUMPTIVES. 

When  on  a  visit  to  Philadelphia  recently,  I  was  delighted  to 
learn  of  the  prospects  for  the  future  growth  of  the  Rush  Hos- 
pital for  consuni]  lion  and  allied  diseases.  This  institution  is 
situated  at  the  northwest  corner  of  Lancaster  Avenue  and  Thirty- 
third  Street  in  the  city  of  Philadelphia.  The  building  first  con- 
sisted of  a  substantially  constructed  mansion,  in  which  fifteen 
patients  could  be  accommodated,  with  rather  undue  crowding. 
Recently  there  has  been  added  a  wing,  extending  northwest  from 
the  original  building,  seventy-two  feet  by  twenty-two  feet.  On  the 
ground-floor  in  this  extension  are  a  waiting-room,  prescribing- 
rooms  for  outdoor  patients,  an  apothecary  shop,  and  a  little  sun- 
parlor.  On  the  second  floor  is  a  ward  which  can  acconmiodate 
fifteen  patients,  and  on  the  third  is  another  ward  which  can  accom- 
modate the  same  number,  with  convenient  bath-rooms,  linen- 
closets,  etc.  Forty  patients  can  now  be  accommodated  in  the 
main  building  without  any  crowding. 


IMPORTANT   SANATORIA   AND   SPECIAL   HOSPITALS. 


i6s 


Patients  are  admitted  in  the  various  stages  of  the  disease,  and  it 
is  to  be  hoped  that  the  noble  efforts  of  the  Women's  Board  of  the 
Rush  Hospital  will  be  crowned  with  success.  The  Rush  Hos- 
pital is  confined  to  the  treatment  of  the  patients,  and  it  is  not 
in  any  sense  a  home  for  consumptives.  It  is  supported  by  volun- 
tary contributions,  to  which  have  been  supplemented,  for  six  years 


■1 


Fig.  s2  —  RisH  Hospital  for  Cokslmi'Uves. 


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past,  an  annual  appropriation  of  $5000  from  the  State  of  Pennsyl- 
vania. 

There  is  a  large  medical  staff  of  consulting  and  visiting  physi- 
cians, composed  of  such  men  as  Stille,  Curtin,  Musser,  Mays, 
Griffith,  S.  Solis-Cohen,  Tyson,  and  others,  which  guarantees  to  the 
institution  a  bright  and  well-deserved  future. 


SHARON   SANITARIUM. 

To  Dr.  Vincent  Y.  Bowditch,  of  Boston,  belongs  the  credit  of 
being  the  first  in  tiiis  country  to  inaugurate  the  sanatorium  treat- 
ment for  the  consumptive  poor  near  large  cities  without  any  con- 
sideration to  special  climatic  conditions.  Thanks  to  his  devotion 
to  the  cause,  and  to  the  generosity  of  wealthy  people  of  the  city 
of  Boston,  the  Sharon  Sanitarium,  at  Sharon,  near  Boston,  was 
erected  in  1891  for  the  treatment  of  consumptives.     Its  object  is  to 


i66 


PULMONARY   TUBERC'JLOSIS. 


1^  \l  il 


■#■■ 

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II II 


admit  people  of  very  limited  means,  like  teachers,  shop-girls,  etc. 
and  not  the  wealthier  classes.  It  is  chiefly  supported  by  public 
subscriptions. 

The  Sharon  Sanitarium  is  a  large,  wooden  building  situated  on  a 
high,  gravelly  knoll  which  slopes  toward  the  south,  at  an  altitude 
of  about  four  hundred  feet,  and  is  sheltered  on  the  north,  west,  and 
east  by  heavy  pine-woods.  It  was  built  especially  for  the  purpose, 
and  can  accommodate  at  present  only  fifteen  women  patients,  but 
in  the  future  the  directors  hope  to  obtain  sufficient  funds  to  erect 


I'"|G.    ,S3.— SllAKON    Sam TARH'M. 

cottages  near  the  present  building  for  the  accommodation  of  both 
sexes.  It  is  so  constructed  as  to  obtain  as  much  fresh  air  and  sun- 
light as  possible,  by  means  of  numerous  windows  and  open  fire- 
places in  every  room. 

F^ach  patient  has  her  own  special  bedroom.  Broad  piazzas 
enable  the  inmates  to  be  much  of  the  time  out-of-doors,  even  in 
the  coldest  weather,  either  walking  or  lying,  well  wrapped  u}),  in 
reclining  chair;;.  The  interior  walls  are  painted,  not  papered ;  the 
floors  are  of  hard  wood,  both  being  frequently  wiped  or  mopped 


IMPORTANT    SANATORIA    AND   SPECIAL    HOSPITALS. 


167 


with  damp  cloths,  and  are  never  dusted  or  swept.  Rugs,  and  no 
fixed  carpets,  are  used. 

The  strictest  rules  are  made  for  the  destruction  of  sputa.  Large 
cuspidors  filled  with  damp  sawdust  are  on  the  lower  floor,  and  the 
contents  destroyed  by  fire.  The  "  Sanitas  "  paper  cups  are  used  at 
the  bedside ;  and  when  upon  the  grounds  each  patient  is  provided 
with  a  rubber  pouch  filled  with  a  roll  of  Japanese  paper,  which  is 
destroyed  also  by  fire  upon  the  patient's  return  to  the  house.  In 
short,  every  precaution  is  taken  to  prevent  possible  infection  from 
the  chief  source  of  danger,  according  to  our  present  knowledge — 
the  dried  sputa. 

To  judge  from  the  reports  which  I  saw  when  I  visited  this  inter- 
esting institution,  and  which  Dr.  Bov/ditch  has  the  courtesy  to 
send  me  from  time  to  time,  all  those  who  feel  that  the  problem  of 
the  tuberculous  poor  must  be  solved  by  the  creation  of  sanatoria 
near  the  large  centres  of  population  cannot  but  feel  highly  en- 
couraged by  the  wo-'k  done  at  Sharon. 


THE   MASSACHUSETTS   STATE    HOSPITAL    FOR    CONSUMPTIVES 
AND   TUBERCULAR   PATIENTS. 

The  opening  of  the  Massachusetts  State  Hospital  for  Consump- 
tives marks  an  era  in  the  history  of  modern  phthisio-therapy.  It 
is  the  first  State  in  this  country  to  take  care  of  its  consumptive 
poor.  The  hospital — wrongly  called  "  hospital,"  for  to  my  mind  it 
deserves,  more  than  any  other,  the  name  of  "  sanatorium  " ' — is 
located  at  Rutland,  Mass.,  on  the  Central  Massachusetts  Railway, 
twelve  miles  from  Worcester,  about  twelve  hundred  feet  above  sea- 
level.  The  construction  of  the  hospital  was  authorized  by  an  act  of 
the  Legislature  of  the  State  of  Massachusetts  in  1895.  It  was  opened 
for  the  reception  of  patients  on  October  i,  1898. 

The  institution  consists  of  a  series  of  two-story  buildings  ar- 
rancred  in  a  half-circle,  in  the  middle  of  which  is  the  administration 
building.  The  pavilions  are  of  two  kinds  :  some  have  seven  small 
rooms  and  a  large  ward  for  twenty-two  patients,  and  others  have 
the  same  number  of  separate  rooms,  but  the  wards  are  smaller  and 
can  accommodate  only  ten  patients.  Each  pavilion  has  a  solarium 
made  entirely  of  glass,  and  all  the  buildings  are  encircled  by  large 

'  See  foot-note  on  pnge  200, 


W: 


m 


V  '  '■'   1 


I 


'    '  I 


I'lii.  54— Massaciu'shtts  Siatk  Huspital  i-or  Consumptives. 

1 68 


' 


IMPORTANT   SANATORIA   AND   SPECIAL   HOSPITALS. 


169 


# 


verandas.  The  pavilions  on  one  side  of  the  administration  build- 
ing are  for  women  and  those  on  the  other  side  are  for  men.  As 
the  accompanying  illustration  shows,  the  buildings  are  all  arranged 
so  as  to  receive  as  much  sun  as  possible.  There  are  in  all  200 
beds.  Patients  can  have  their  choice  in  regard  to  the  treatment — 
that  is  to  say,  whether  they  desire  to  have  a  regular  or  a  homoeo- 
pathic physician  for  their  attendant. 

What  makes  this  institution  particularly  interesting  is  that,  inas- 
much as  its  primary  purpose  is  to  arrest  the  disease,  and  if  possible 
to  extirpate  it,  only  such  patients  will  be  admitted  as  are  deemed 
not  too  far  advanced  to  admit  of  reasonable  hope  of  radical  im- 
provement. In  no  sense  is  the  hospital  to  be  considered  as  a  home 
for  the  hopelessly  sick ;  for,  great  as  is  the  recognized  need  for 
homes  of  refuge  for  advanced  consumptives,  such  service  is  mani- 
festly incompatible  with  the  even  more  needed  service  of  rescuing 
lives  that  can  be  saved  only  by  sanatorium  treatment.  "  Patients 
who  do  not  improve  after  a  stay  in  the  hospital  sufficiently  long  to 
test  the  effect  of  treatment  will  be  advised  not  to  remain,  and  their 
friends  will  be  expected  to  arrange  for  their  removal  to  surround- 
ings primarily  devoted  or  better  adapted  to  their  comfort." 

This  is  a  clause  contained  in  the  opening  announcement,  and  is 
one  of  the  most  distinct  features  of  the  work  of  the  institution.  The 
fact  that  the  charges  for  patients  are  uniform  and  only  fifty  cents 
a  day,  that  no  private  patient  will  be  received,  and  that  private 
rooms  will  be  allowed  only  for  physical  reasons,  and,  finally,  that 
no  extra  charges  will  be  made  and  no  fees  and  tips  allowed  to  be 
accepted  under  any  circumstances,  makes  this  institution  in  the 
truest  sense  a  philanthropical  one. 

The  visiting  and  examining  physicians  are  Drs.  Vincent  Y.  Bow- 
ditch  (regular)  and  Herbert  C.  Clapp  for  the  homoeopathic  divi- 
sion. The  medical  superintendent,  who  resides  at  the  Rutland 
institution,  is  Dr.  Walter  J.  Marclay. 


THE  FREE  HOME  FOR  CONSUMPTIVES  IN  THE  CITY  OF  BOSTON. 

Realizing  the  necessity  of  a  non-sectarian  home  for  poor  con- 
sumptives, the  Young  Ladies'  Charitable  Association  (whose  object 
is  to  care  for  the  sick  poor)  was  organized  in  March,  1891.  It 
purchased  a  large  estate  in  Dorchester,  Mass.,  and  in  March,  1892, 
after  making  necessary  alterations  in  the  mansion-house,  opened 


m 

"f'S 

m 


170 


PULMONARV  TUBERCULOSIS. 


the  original  building  under  the  incorporated  name  of  "  The  Free 
Home  for  Consumptives  in  the  City  of  Boston." 

The  great  number  of  applications  for  admission  has  necessitated 
the  erection  of  a  larger  building,  which  has  just  been  completed. 
The  buildings,  consisting  of  the  administration  building,  a  portion 
of  which  is  used  for  nurses  and  attendants,  and  the  main  building, 
which  has  accommodations  for  over  one  hundred  and  twenty-five 
patients,  are  constructed  of  wood  in  the  colonial  style  of  architect- 
ure, and  are  set  back  from  the  street  a  distance  of  150  feet.  The 
grounds  facing  the  street  are  laid  out  and  planted,  and  a  large 
space  in  the  rear  of  the  administration  building  is  reserved  as  a 
recreation  field  for  the  patients. 


Fig.  55.— Genkrai.  Vikw  hi'  thk  Krke  Homk  for  CossuMPTiviiS  in  the  City  of  Boston. 

In  planning  these  buildings  the  purpose  was  to  secure  an  ar- 
rangement embodying  all  the  salient  features  which  are  so  impor- 
tant in  a  hospital  of  this  kind,  and  also  to  make  it  homelike  as  well. 
This  result  was  attained,  as  will  be  seen  by  the  plan,  by  placing  the 
various  wards  on  the  .southern  side  of  the  main  corridor,  which 
runs  the  entire  length  of  the  building,  and  connecting  them  by 
large  sliding-doors  with  a  recreation  hall  in  the  centre,  which  is 
open  to  the  third  floor.  Here  concerts  are  given  once  a  week  by 
the  different  district  committees  which  compose  the  Young  Ladies' 
Charitable  As.sociation,thus  affording  tho.se  patients  who  are  unable 
to  be  about  an  opportunity  of  sharing  the  enjoyment  with  their 
more  fortunate  companions. 

The  dining-hall,   serving-kitchen,  toilet-rooms,    reading-rooms, 


IMPORTANT   SANATORIA    AND   SPECIAL   HOSPITALS. 


171 


linen-rooms,  and  rooms  for  patients'  clothing,  are  located  on  the 
north  side  of  the  corridor.  At  the  extreme  end  of  the  main  cor- 
ridor are  grouped  the  wards  for  isolated  patients,  which  are  shut 
off  from  the  rest  of  the  building,  and  are  fitted  up  with  toilet- 
rooms,  etc.,  for  their  use. 

The  front  entrance,  which  is  used  for  visitors,  is  through  a  vesti- 
bule into  a  large,  central  hall,  which  is  finished  and  paneled  in 
quartered  oak,  and  is  made  attractive  by  a  large,  open  fireplace, 
and  a  spacious  staircase  which  leads  to  the  second  and  third  floors. 
Grouped  about  this  hall  are  the  reception-room,  nurses'  parlor,  and 
the  throat-  and  consulting-room,  which  is  also  easy  of  access  from 
the  administration  building,  adjoining  it  on  the  left.  The  consult- 
ing-room is  fitted  with  toilet,  etc.,  for  the  use  of  the  doctors,  and  it 
also  has  an  open  fireplace,  which  gives  it  a  cheerful  appearance  and 
affords  an  excellent  means  of  ventilation.  In  the  basement  are 
located  the  laundry,  drying-room,  inhalation-room,  funiigating- 
room,  kitchen,  etc.  The  second  floor  is  arranged  in  much  the 
same  manner  as  the  first  floor,  with  the  exception  that  on  the  south- 
we.st  front  are  two  additional  wards,  accommodating  eight  beds 
each,  and  a  small  chapel  over  the  first  entrance. 

The  building  is  finished  in  brown  ash  and  quartered  oak,  and  the 
floors  throughout,  except  the  rooms  in  the  basement,  are  laid  out 
with  rift  hard  pine.  As  a  protection  against  fire,  brick  walls  have 
been  introduced  every  fifty  feet,  which  run  clear  across  the  build- 
ing, in  the  openings  of  which  are  hung  metal,  fireproof  doors,  so 
that  in  case  of  fire  the  doors  may  be  closed  and  the  fire  confined 
to  any  particular  section.  The  plumbing  has  been  arranged 
according  to  modern  sanitary  principles.  The  heating  and  ventilat- 
ing system  is  known  as  the  plenum  or  fan  system.  The  air  is 
introduced  at  a  central  point  and  passed  over  tempering  coils,  and 
h-.Mted  to  a  temperature  varying  from  60°  to  70°  F.,  as  may  be 
required,  and  then  forced  by  a  seven-foot  fan  through  the  various 
galvanized-iron  ducts  to  the  heat-flues,  at  the  base  of  which  are 
supplementary  coils,  which  bring  the  temperature  up  to  any  degree 
desired.  Dampers  are  placed  at  the  base  of  each  heat-duct,  which 
are  controlled  by  the  nurse  in  each  ward  or  room,  and  can  be 
manipulated  so  as  to  give  any  temperature  desired  in  any  room  or 
ward.  The  ventilation  is  extended  to  all  the  rooms  throughout 
the  building,  including  kitchen,  bakery,  laundry,  toilet-rooms,  and 


li 

I 


172 


PULMONARY   TUUERCULOSIS. 


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IMI'ORTANT   SANATORIA    AND   SPECIAL   HOSI'ITALS. 


'73 


also  corridors.     The  air-supply  is  on  a  basis  of  seventy  cubic  feet  per 
minute  for  each  cot,  and  for  eacli  of  four  additional  occupants. 

The  medical  staff  is  composed  of  Drs,  M.  O.  Otis,  R.  M.  Merrick, 
and  H.  M.  R.  Watts  as  visitin<^  physicians,  and  ten  consulting  phy- 
sicians, with  Dr.  Frederick  I.  Knight  as  chairman. 


THE  WINYAH  SANITARIUM. 

This  institution  was  foumit'd  a  number  of  years  ago  by  Dr.  J.  W. 
Gleitsmaiin.of  New  York,  for  the  purpose  of  giving  to  the  wealthier 
class  of  consumptives  the  benefit  of  the  hygienic  and  dietetic  treat- 
ment in  a  sanatorium,  combined  with  the  climatic  advantages  which 
North  Carolina  offers.  This  sanatorium,  which  I  visited  in  189", 
is  located  at  Asheville,  and  is  now  under  the  direction  of  Dr.  Karl 
von  Ruck.  It  consists  of  a  large  building  with  verandas,  accom- 
modating about  one  hundred  patients.  Very  interesting  to  me 
was  the  well-equipped  laboratory  for  bacteriological  research 
attached  to  Dr.  von  Ruck's  institution. 

Since  my  visit  to  Asheville  I  learn  that  plans  for  a  new  and  much 
larger  institution  have  been  decided  upon.  The  new  sanatorium 
will  be  located  in  a  grove  of  oak  and  pines,  twenty  acres  in  extent, 
adjoining  the  city.  The  buildings  are  to  consist  of  a  main  building 
with  the  necessary  public  rooms,  baths,  hydropathic-treatment 
rooms,  and  twenty-four  private  rooms  for  patients,  together  with 
several  suits  of  rooms  with  private  baths.  The  construction  will 
be  modern  and  in  compliance  with  the  most  advanced  principles 
of  sanitary  science,  but  with  special  reference  to  its  occupation  by 
phthisical  patients.  Tlic  heating  will  be  with  open  fires  in  all  pub- 
lic and  private  rooms,  but  steam-heat  will  also  be  supplied  by  indi- 
rect radiation,  thus  heating  the  outside  air  and  delivering  it  into 
the  different  apartments.  Abundance  of  sunlight  is  to  be  secured 
for  all  rooms,  corridors,  etc. 

In  addition  there  will  be  two  cottages,  one  of  four  and  another 
of  seven  rooms,  which  will  be  constructed  and  equipped  the  same 
as  the  main  building.  Additions  to  the  capacity  of  the  institution 
will  be  made  by  the  erection  of  new  cottages  as  the  patronage  may 
justify.  Besides  these,  there  will  be  a  laboratory  of  si.-nl  rooms, 
with  perfect  equipment  for  the  study  of  tuberculosis. 

No  advanced  or  hopeless  cases  will  be  admitted. 


.  ii 


I'Mi 


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'if.-.  I 


t-  'ii 


174 


PULMONARY   TUHERCUI.OSIS. 


THE  ASHKVIl.l-b  SANATORIUM    FOR    DISEASES    OF  THE    CHEST 

AND  THROAT. 

On  tlie  summit  of  a  lar^je,  wooded  eminence  known  as  "Oakland 
Heights,"  overlooking  Aslieville  and  one  mile  to  the  south  of  it, 
arises  a  second  sanatorium,  recently  built  in  tiiat  city.  It  is  under 
the  medical  management  of  S.  Westrey  liattle,  M.D.,U.S.N.,  and 
John  W.  Ross.  M.D.,  U.  S.  N. 

The  view  from  the  sanatorium  is  one  of  surprising  loveliness — a 
panorama  of  city,  rivers,  valleys,  forests,  and  distant  mountains. 
The  building  is  a  substantial  ami  ornamental  structure,  of  three 
stories  anil  basement,  designed  for  sanatorium  purposes,  and  con- 
tains eighty  rooms.     The  appointments  are  motiern,  with  elevator, 


!    .1 


ill; 


I'ltj.   5;.— AsllKVU.LK  SANATURILM, 

electric  lights,  etc.  The  basement,  which  is  on  the  level  of  the 
ground,  is  devoted  to  the  bath  establishment  and  gymnasium,  in- 
cluding a  swimming-pool.  The  house  is  provided  above  and  below 
with  numerous  sunny,  sheltered  verandas  and  porches. 

The  capacity  of  the  sanatorium  is  seventy-five  patients. 

The  advantages  of  having  all  the  patients  under  one  extensive 
roof  are  obvious,  the  chief  one  being  that  they  can  be  more  easily 
and  constantly  watched  over. 

The  grounds  consist  of  fifteen  acres  of  park  land  covered  with 
an  open  growth  of  handsome  oaks,  interspersed  with  pines.  The 
adjacent  territory  is  especially  suited  for  exercise  on  foot  or  horse- 
back, mountain-climbing,  etc. 


IMPOKTANT  SANATOKIA  AND  Sl'ECIAI.  IIOSI'ITAI.S. 


'75 


The  sanatorium  was  opened  on  the  ist  of  March,  1.S98.  Tlie 
treatment  in  tiie  sanatorium  is,  of  course,  the  hj'^ienic  and  dietetic, 
with  all  its  various  adjuncts  (hydrotherapy,  massa<;e,  etc.).  The 
sanatorium  is  bountifully  supfjlied  with  remarkably  pure  water 
for  drinking  and  all  other  purposes,  from  its  own  spring,  the 
large  stream  from  whicti  does  not  vary  perceptibly  in  quality  or 
quantity  during  wet  or  dry  weather.  In  addition,  the  perfect 
system  of  sewerage  will  be  flushed  with  water  from  the  city  water- 
works, and  all  sewage,  after  having  been  disinfected,  will  be  dis- 
charged into  the  French  Broad  River,  one  mile  away. 

One  of  the  medical  directors  resides  permanently  in  the  sanato- 
rium. 


Fig.  58.— Main  Building  ok  thk  Sanavorium  Hvgeia  at  Citronklle. 


THE  HYGEIA. 
Two  years  ago  there  was  founded  at  Citronelle,  Ala.,  by  Dr.  A. 
C.  Klebs,  son  of  Professor  Edwin  Klebs,  of  Chica;_^o,  a  sanatorium 
for  consumptives.     It  is  now   under   the  management  of  Dr.  J.  G. 


\'- 


f!    ■; 


4;,-. 


Vi. 


I 


1 


176 


PULMONARY   TUBERCULOSIS. 


Michael,  with  Dr.  Keitli  Fondc  as  house-physician, and  has  become 
an  institution  open  all  the  year. 

Citronelle  is  situated  almost  in  the  centre  of  tiie  high  pine-forest 
of  South  Alabama,  sixty-two  miles  from  the  Gulf  of  Mexico,  and 
thirty-three  miles  north  of  Mobile.  It  lias  an  elevation  of  360 
feet  above  the  level  of  Mobile  Bay.  It  is  the  highest  point,  within 
this  distance  of  the  coast,  between  Boston  and  Galveston,  and  the 
highest  point  on  the   Mobile  and  Ohio  Railroad  between  Mobile 


'■^i-Mm 

lawmi-iirTnir  "'^i9»d 

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3  *"■   ' 

1 

1, 

Fig.  59.— Cottagks  t.tv  thk  Sanakirm  m  Hygkia  ai   Cn  koniiIJ.k. 

and  St.  Louis.  The  elevation  and  the  surrounding  pine-covered 
hills  give  to  Citronelle  perfect  drainage  and  pure  water.  The  warm 
waters  of  the  Gulf  of  Mexico  modify  the  winter  temperature,  and 
the  height  at  which  the  sanatorium  is  built  protects  it  from  too 
much  moisture  from  the  sea.  It  is  also  sufficiently  removed  from 
the  neighborhood  of  malarial  swamps. 

The  United  States  weather  reports  for  each  of  the  months  of 
December,  January,  February,  and  March  show  that,  at  Citronelle, 
the  minimum  temperatures  average  fifteen  degrees  higher  than  at 


f  ^1 


IMPORTANT    SANATORIA    AND    SPECIAI,    IIOSPITAI5. 


'// 


Aslieville,  North  Carolina.  The  average  maxinuini  for  the  same 
period  shows  seven  degrees  warmer  here. 

The  "  Hygeia  "  includes  three  l.irge  buildings  and  five  cottages. 
The  main  building  contains  dining-room,  jjarlors,  reading-room,  and 
business  office,  and  a  number  of  comfortable  bedrooms  for  guests. 
In  the  fall  of  1898  all  the  buildings  were  repainted  inside  and  out  ; 
new  bedding  and  furniture  were  placed  in  all  sleeping-apartments ; 
electric  bells  and  modern  sanitary  appliances  have  been  added. 
Most  of  the  bedrooms  are  sup[)lied  with  open  fireplaces,  thus  insur- 
ing good  ventilation  and  warmth. 

For  the  entertainment  of  the  guests  and  patients  there  are 
a  billiard-room  and  bowling-alley;  also  beautiful  grounds  for 
croquet,  lawn-tennis  courts,  and  golf  links.  Besides  this  there  are 
well-kept  walks  and  roads,  which  give  ample  opportunity  for 
beneficial  exercise.  There  is,  during  the  winter,  excellent  quail- 
shooting. 

To  judge  from  a  recent  announcement  which  Dr.  Fonde  kindly 
sent  me,  the  "  Hygeia  "  is  as  much  a  hotel  as  a  sanatorium,  and  thus 
I  do  not  think  we  can  class  it  as  a  closed  establishment  in  the 
strict  sense  of  the  word.  The  fact,  however,  that  the  institution 
consists  of  large  pavilions  should  make  a  division  arid  .strict  sani- 
tary supervision  easy.  There  are  appliances  for  inhalation,  mas- 
sage, bath,  and  electricity.  There  is  a  special  railroad-station 
immediately  in  front  of  the  hotel. 


"THE  HOME"  AT  DENVER,  COLORADO. 

With  a  well-meant  purpose,  the  Protestant  Episcopal  Church 
has  created,  near  the  beautiful  city  of  Denver,  a  large  institution  for 
consumptives  of  the  middle  classes.  It  is  called  "The  Home," 
and  can  be  reached  in  fifteen  minutes  from  the  centre  of  Denver; 
three  car-lines  pass  the  institution.  From  the  Home  one  has  a 
commanding  view  over  the  entire  city,  the  plains  for  hundreds  of 
miles,  and  the  Rockies  for  150  miles,  with  an  uninterrupted  view 
of  Pike's  Peak,  Grey's  Peak,  and  Long's  Peak. 

The  institution  has  a  southern  exposure,  and  comprises  three 
buildings  in  colonial  style:  "St.  Andrew's  House"  for  men, 
"  Grace  House"  for  mother  and  son,  or  husband  and  wife,  and  the 
"  Emily  House"  for  women.  These  cover  an  entire  block  of  land, 
and  are  connected  by  a  glass  and  covered  [)orch  called  the 
12 


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IMPORTANT   SANATORIA   AND   SPECIAL   HOSPITALS. 


•79 


"  Cloister."  There  are  covered  and  uncovered  porches  front  and 
back,  upstairs  and  down-stairs  ;  a  music-room  ;  a  library  containinj^ 
2000  vohinies;  a  <jvmnasiiiiii  containiiiir  bilh'ard-tables,  cliest- 
\vei<^hts,  Indian  clubs,  dumb-bells,  etc.  There  are  parlors  in  each 
of  the  buildings.  In  one  hangs  a  very  valuable  oil  picture,  an  old 
copy  of  one  of  the  Holy  Families,  painted  by  Raphael.  I^ath- 
rooms,  lavatories,  and  closets  are  in  great  abundance.  There  are 
accoumiodations  for  eighty  people.  Each  room  is  separated  from 
the  adjoining  rooms  by  a  brick  partition.  The  walls  are  hard 
finish  and  the  floors  are  hard  wood.  There  is  a  large,  attractive 
dining-room. 

The  Rev.  Frederick  W.  Oakes  is  the  superintendent  of  the 
institution.  It  is  calculated  to  be  self-supporting.  Patients  pay 
one  dollar  per  day  and  receive  for  this  board  and  room.  They 
have  the  right  to  choose  their  medical  attendant. 

When  I  visited  this  beautiful  institution,  my  first  disappointment 
was  to  learn  that  the  Home  had  no  house-physician.  I  passed 
through  the  corridors,  library,  and  dining-room,  and  looked  at 
the  many  cheerful  and  bright  bedrooms.  The  air  outside  was 
brisk  and  clear,  and  the  sun  shone;  but  not  one  window  was  open, 
and  the  atmosphere  inside  of  the  institution  was  far  too  warm,  and 
certainly  not  fresh  enough  to  be  of  any  benefit  to  the  patients,  who 
were  nearly  all  indoors.  While  I  have  no  doubt  that  every  pre- 
caution is  taken  on  the  part  of  the  management  in  regard  to 
the  sputum,  to  supervise  constantly  eighty-odd  tuberculous 
patients  and  .see  that  there  should  never  be  any  violation  of 
the  sanitary  rules  and  regulations  of  the  house,  requires  more 
than  the  gentle  hand  of  a  minister  or  matron.  Aside  from  this,  it 
is  my  firm  conviction  that,  in  the  interest  of  the  patients,  as  well 
as  in  the  interest  of  the  comm unity -at-large,  there  should  never 
be  so  great  a  number  of  tuberculous  invalids  without  the  constant 
presence  of  a  medical  attendant.  At  no  period  in  the  course  of 
the  disea.se  should  the  tuberculous  patient  be  "  kept  "  ;  he  should 
always  be  treated.  I  make  this  criticism  in  the  spirit  of  kindness, 
for  I  think  it  just  as  essential  to  describe  existing  defects  as  to 
emphasize  the  advantages  which  the  various  institutions  I  visited 
had  to  offer. 

The  beautiful  photograph  which  I  reproduce  here  Avill  give  a 
good  idea  of  the  institution,  which  is  the  result  of  the  efforts  of 
noble-minded  men  and  women.     Their  aims  cannot  be  praised  too 


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PULMONARY   TUBERCULOSIS, 


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highly,  but  if  the  institution  would  be  transformed  into  a  sana- 
torium, as  understood  by  modern  phthisio-therapeutists,  the  good 
which  would  be  done  would  far  exceed  the  work  accomplished  by 
the  Home  in  its  present  state. 


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GLOCKNER  SANITARIUM. 

The  Glockner  Sanitarium  is  situated  at  Colorado  Springs,  Col. 
The  climate  of  the  region  has  been  studied  and  described  by 
Weber,  Denison,  and  Solly.  The  latter  says,  in  his  comparative 
merits  of  American  resorts,  that  "  Colorado  Springs,  6000  feet 
above  the  sea,  has  about  the  same  winter  temperature  as  Denver  ; 
is  slightly  drier;  has  less  snow,  but  rather  more  wind.  It  was 
laid  out  as  a  health  resort  upon  a  mesa,  near  to,  but  sufficiently 
removed  from,  the  shadow  of  Pike's  Peak.  It  is  a  handsome  resi- 
dential town,  without  manufactories  and  with  first-class  resources 
of  all  kinds  and  beautiful  suburbs."  ' 

Colorado  Springs  is  situated  on  a  vast  plateau,  and,  though 
inclosed  by  the  Rockies  and  foot-hills,  it  receives,  nevertheless,  its 
full  share  of  insolation  and  is  free  from  excessive  heat  and  intense 
cold.  The  Glockner  institution  is  situated  at  the  northern  end  of 
the  city  and  is  easily  accessible  by^electric  cars  in  fifteen  minutes. 

From  the  circular  the  Sister  Superior  very  kindly  handed  me,  on 
my  recent  visit  to  the  institution,  I  give  the  following  extract,  which 
describes  the  institution  and  its  aims : 

"  The  house  was  designed  and  built  for  the  special  care  of  pul- 
monary complaints,  though  it  welcomes  other  invalids  also.  It  is 
supplied  with  every  modern  convenience  and  appliance.  It  is  so 
constructed  that  every  room  receives  the  sun.  It  is  furnished,  on 
every  story,  with  ample  porclies,  some  entirely  open,  so  as  to 
receive  all  the  influence  of  the  air  and  sun  ;  some  covered,  for  e.xer- 
cise  and  air  in  inclement  weather;  some  completely  inclosed  in 
glass,  giving  all  the  benefit  of  the  sun,  while  sheltered  from  the  air. 
An  electric  elevator  reaches  every  floor.  Electric  lights  are  in 
every  room  and  hall.  Klegant  sitting-  and  reading-rooms  afford 
opportunity  for  social  enjoyment.  .Spacious  grounds  and  lawns 
relieve  the  eye  and  furnish  pleasant  walks.  In  order  to  facilitate 
life  in  tiic  open  air,  so  beneficial  in  pulmonary  disorders,  a  numbt-r 


•  "Transactions  of  the  Ainer.  C'liniat.  .Vssoc,"  vol.  \iii,  p.  i8r. 


IMPORTANT   SANATORIA   AND   SPECIAL    HOSPITALS. 


I8l 


of  tents  liave  been  erected  on  the  grounds,  in  wliich  patients  may 
spend  botli  day  and  niglit,  if  so  disposed.  It  lias  been  made  a 
point  to  keep  a  table  of  the  highest  grade,  in  which  the  dishes  are 
of  a  variety  to  suit  every  taste,  and  are  prepared  and  served  with 
the  greatest  care.  The  house  is  owned  and  managed  by  the  Sisters 
of  Charit)'." 

This  speaks  for  itself  as  to  how  far  the  i.istitution  is  from  a  sana- 
torium— or  closed  establishment — in  the  meaning  of  the  word  as 
now  interpreted.  There  is  no  house-physician,  and  the  hygienic 
and  sanitary  supervision  is  in  the  hands  of  the  Sisters  of  Charity. 


THE   BROOKLYN   HOME   FOR   CONSUiMPTlVES. 

With  an  object  similar  to  the  institution  just  described,  the  Brook- 
lyn Home  for  Consumptivos  was  founded  in  i<S8i.  It  is,  however, 
non-sectarian,  and  nearly  all  the  churches  of  Brooklyn  are  contrib- 
utors. 

The  "  Home  "  is  a  larf^e,  comfortable  building,  situated  at  the 
corner  of  Butler  and  Douglass  Streets,  in  the  borough  of  Brook- 
lyn. It  can  accommodate  ninety-two  patients.  The  institution  is 
under  the  energetic  management  of  Mrs.  S.  V.  White,  its  president, 
with  a  number  of  ladies  to  aid  her.  The  last  annual  announce- 
ment, which  the  matron-in-charge  had  the  courtesy  to  give  me 
when  I  visited  the  institution,  speaks  of  a  report  of  "  allopathic 
physicians  "  and  of  a  report  of  "  homoeopathic  physicians,"  The 
former  states  that  the  number  of — 

Patients  tre.ited  during  tlie  year  was 152 

Died  during;  the  year, 58 

I-eft,  improved, 22 

Left  with  permission, 7 

Left  without  permission, 3 

Discliarned,      3 

Sent  to  hospital,       I 

Remaiiiinjj  ni  Home, 58 

The  homteopathic  physicians  gave  the  following  statement: 

Patients  treated  during  the  year, 84 

Died  during  the  year, 27 

Left,  ii)i|iroved, 17 

Left,  unimproved, 6 

Left  witiiout  pcunission, 6 

Sent  toiiospital I 

KeinuininiT  in  llcinie, 2" 


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The  institution  is  entirely  free  to  the  poor,  and  th^s,  no  doubt, 
doing  good  work  by  accepting  even  the  advanced  cases.  But  the 
same  criticism  which  I  made  in  regard  to  the  Denver  Home  is 
appHcable  to  the  Brooklyn  Home.  There  is  not  a  sufficient  hygi- 
enic supervision,  and  no  medical  attendant  resides  in  the  house. 


CANADA. 

THE  MUSKOKA  COTTAGE  SANATORIUM. 

This  institution,  situated  at  Gravenhurst,  Ont.,  was  opened  on  the 
1st  of  September,  1897.  It  is  the  first  of  a  number  of  Canadian 
sanatoria  which  are  to  be  erected  by  the  National  Sanatorium  As- 
sociation— an  association  founded  by  a  number  of  philanthropists, 
and  incorporated  by  special  act  of  the  Parliament  of  Canada,  with 
an  object  "  to  establish  public  institutions  for  the  isolation,  treat- 
ment, and  cure  of  persons  affected  with  pulmonary  disease." 

The  sanatorium  is  situated  on  the  shores  of  Lake  Muskoka,  125 
miles  north  of  Toronto,  Ontario.  All  the  buildings  have  their 
frontage  to  the  south.  The  elevation  is  about  1000  feet.  The  air 
is  bracing,  dry,  and  free  from  dust.  The  region  is  very  rocky,  there 
being  little  farm  land  in  the  district.  The  formation  is  entirely 
Laurentian  ;  the  water  is  consequently  free  from  lime,  and  is  very 
soft.  To  the  north  and  west  are  rocky  bluffs,  and,  except  on  the 
south,  the  buildings  are  surrounded  by  a  wood  of  beech,  maple,  and 
balsamic  trees.  To  the  south  a  terraced  lawn  stretches  from  the 
buildings  to  the  shore  of  the  lake.  As  the  name  indicates,  the 
cottage  plan  of  treatment  has  been  adopted.  In  the  administration 
building  there  are  rooms  for  twenty  patients.  In  it  are  also  the 
offices,  reception-  and  music-room,  reading-room,  broad,  spacious 
hallways,  kitchen,  dining-room,  and  three  solaria;  one  solarium 
faces  the  east;  a  second,  southeast;  the  third,  southwest.  Along 
the  front  of  the  building  is  a  broad  piazza,  on  which  the  sun  shines 
fnsm  morning  until  night,  and  above  this,  on  the  second  floor,  an 
open  balcony  of  the  same  width. 

None  of  the  cottages  accommodate  more  than  six  patients,  some 
being  limited  to  four.  I'^ach  cottage  has  a  large  sitting-room,  in 
which  is  an  open  fireplace.  Theie  is  also  a  large  piazza,  so  ar- 
ranged that  it  may  be  partially  inclosed  with  glass  during  the 
winter.     All  the  buildings  are  lighted  by  electricity.     The  main 


IMPORTANT   SANATORIA    AND   SHECIAL   HOSPITALS. 


183 


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PULMONARY   TUBERCULOSIS. 


builcliiig  is  heated  by  steam,  the  cotta<;es  by  hot  water.  During 
the  cooler  nights  of  early  fall  and  late  spring  the  fireplaces  are 
used.  Only  fifty  patients  can  be  accommodated  at  present,  but  the 
number  of  cottages  will  be  increased  until  there  is  room  for  about 
ninety  patients. 

There  are  no  wards ;  each  patient  has  a  separate  room.  The 
rooms  are  large  and  well  ventilated ;  each  is  so  situated  as  to 
receive  the  sun  during  .some  part  of  the  day.  The  interior  of  the 
building  is  finished  in  birch,  with  white  walls  above  the  wainscot. 
The  floors  throughout  are  of  hard  wood. 

Artificial  paths  of  various  gradients  have  been  made  throughout 
the  grounds.     Although  in  such  proximity  to  the  water,  the  air  is 


riG.  62.— A  COTIAGK  OK  Mlskoka  Cottagk  Sanatoril.m. 

quite  dry,  and  the  patients  can  avail  themselves  of  excellent  boating 
facilities  and  daily  excursions  up  the  lakes  for  a  few  hours  or  the 
whole  day. 

The  meals  are  at  eight,  one,  and  six,  with  lunches  at  eleven,  four, 
and  nine  ;  all  retire  at  ten. 

The  :iHnatoriuni  is  open  throughout  the  year,  the  results  in 
winter  being  fully  as  satisfactory  as  in  summer.  The  nights  in 
summer  are  quite  cool.  In  winter  there  are  no  sudden  changes  in 
temperature.  Snow  lies  on  the  ground  from  December  until  March, 
with  steady  frost.  There  is  a  maximum  of  sunshine.  The  patients 
are  able  to  live  on  the  verandas  six  to  eight  hours  a  day  through- 
out the  winter.     The  paths  are   kept  clear  of  snow  for  walking. 


IMPORTANT    SANATORIA    AND    SPECIAL    HOSPITALS. 


IS5 


Considerable  driving  is  done  during  the  sleighing  season.     .Sno\ 
shoeing  is  also  a  favorite  pastime  and  exercise  for  suitable  cases. 

The  sanatorium  is  devoted  to  the  treatment  of  pulmonary  phthisis. 
The  cost  to  each  patient  is  six  dollars  per  week,  inchidinv  meiii- 
cine.  The  results  for  the  first  six  months  have  been  (juite  satis- 
factory, though  much  better  figures  would  be  given  did  the  finances 
of  the  patients  allow  them  to  remain  longer  under  treatment. 
Only  patients  will  be  admitted  who  are  in  an  early  stage  of  con- 
sumption, and  to  whom  residence  for  a  number  of  months  in  the 
sanatorium  promises  either  a  complete  cure,  or  such  an  improved 
condition  that  they  may  be  able  to  return  to  their  homes  to  carry 
on  their  work.  The  sanatorium  reserves  the  right  to  dismiss  a 
patient  at  any  time. 

The  physician-in-charge  is  Dr.  J.  H.  Elliott;  the  examining 
physician  for  Toronto  is  Dr.  N.  A.  Powell,  and  for  Montreal,  Dr. 
James  Stewart. 


THE  LAURENTIAN  SANATORIUM. 

This  Canadian  establishment,  with  limited  accommodation  for 
twenty-five  patients,  is  situated  in  a  small  valley  formed  by  the 
chain  of  mountains  bearing  the  name"  Laurentian,"  at  an  elevation 
of  nearly  two  thousand  feet.  It  is  partially  exposed  to  the  north, 
but  principally  to  the  southeast;  in  spite  of  this  partial  northern 
exposure  it  is  sufficiently  well  protected  by  distant  hills.  The  dry 
air  in  this  region  is  particularly  well  adapted  for  the  out-door  life 
which  the  patients  are  enjoined  constantly  to  follow.  During  the 
winter  the  typical  Canadian  cold  weather  does  not  offer  any  serious 
objections  to  the  outdoor  life  of  the  patients;  owing  to  the  lack  of 
moisture,  the  patients  may  be  allowed  to  lounge  in  the  open  air  for 
hours  in  perfect  comfort,  provided  they  are  well  wrapped  up  in 
woolen  clothing. 

This  sanatorium  is  situated  at  about  one  mile  from  the  village 
of  St.  Agathe  des  Monts,  and  at  about  an  equal  distance  from  the 
railway  station.  St.  Agathe  is  sixty-four  miles  from  Montreal, 
and  is  reached  by  a  branch  li;ie  of  the  Canadian  Pacific  Railwa)'. 
This  line  was  built  some  few  years  ago  through  a  wild,  mountainous 
district,  and  now  one  sees  here  and  there  small  villages  on  each 
side  of  the  railway.  From  the  railway  cars  one  is  treated  to  natural 
scenes  almost  as  grand  as  those  to  be  seen  in  the  Alps.  From  the 
summit  of  a  small  mountain  risip^r  behind  the  sanatorium  one  can 


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IMHOKTANT   SANATORIA   AND   *:PECIAL    IlOStMTALS. 


187 


count  seven  lakes,  both  l.irgc  and  small,  in  the  almost  immediate 
vicinity.  The  Laurentian  Mountains  are  generally  admitted  as 
being  the  oldest  mountain  range  in  the  world.  It  is  in  reality  a 
sporting  paradise,  with  innumerable  lakes  and  forests,  a  great 
number  of  which  are  still  unexplored. 

The  water  for  the  sanatorium  comes  from  a  spring  capable  of 
supplying  from  twenty  to  thirty  gallons  per  minute.  Electricity  is 
utilized  for  lighting  the  sanatorium.  Two  glass  inclosed  verandas, 
each  provided  with  fireplaces,  add  to  the  comfort  ol  the  patients, 
especially  during  the  colder  season.  Drives  and  supervised  walks 
offer  a  certain  amount  of  diversion  for  the  patients  able  to  indulge 
in  them. 

Trained  nurses  are  in  constant  attendance  upon  those  patients 
who  requiie  their  services.  The  nurses  also  have  to  keep  a  record 
of  the  pulse,  tempt  rature,  and  respiration,  as  well  as  note  condition 
of  the  patients  in  t  ir  charge,  for  the  control  of  the  attending  phy- 
sician. Patients  wii  se  temperature  does  no*^  exceed  99°  F.  are 
^iven  a  certain  amount  of  freedom  in  a  limited  measure.  Sun- 
boxes  are  here  and  there  to  f^e  found,  distributei.  over  a  large  area 
of  ground,  where  the  patients  can  take  an  occasional  rest  during 
their  walks. 

This  sanatorium,  having  been  only  rec-ntly  built  (1898),  pro- 
vides no  luxuries  w'latever :  but  with  time,  improvements  will  be 
made  for  the  comfort  and  wei. -being  of  the  patient > 

The  sanatorium  is  under  the  direction  of  Dr.  A.  J.  Richer,  of 
Montreal.  The  admission  of  patients  is  made  upon  the  recom- 
mendp*^'nn  of  Dr.  H.  A.  La  Fleur,  Associate  Professor  of  Medicine 
at  lie  ri:  College,  Montreal.  This  gentleman  is  also  consulting 
physic ia'^  to  the  sanatorium.  The  therapeutical  department  is 
direct. :d  by  Dr.  Robert  Wilson,  Professor  of  Materia  Medica  and 
Therapeutics  at  Bishop's  College,  Montreal. 


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CHAPTER  X. 


] 


. '   '.? 


CLIMATO-THERAPY   IN    THE   TREATMENT   OF 
PULMONARY   TUBERCULOSIS. 

Among  the  methods  of  curing  pulmonary  tuberculosis  I  wish 
to  consider,  first,  the  treatment  in  sanatoria,'  or,  ar.  the  Ger- 
mans call  it,  the  hygienic  and  dietetic  treatment  in  closed  estab- 
lishments, because  I  think  it  the  most  important  of  all.  I  have 
convinced  myself,  by  actual  experience  as  an  assistant  in  an  impor- 
tant institution  of  this  kind,  and  by  visiting  in  person  nearly  all  the 
principal  sanatoria  for  consumptives  in  Europe  and  the  United 
States,  that  the  tuberculous  patient  has  the  best  chances  of  getting 
well  only  when  he  is  under  constant  medical  supervision.  My 
observations  in  this  direction  have  been  confirmed  by  comparing  the 
results  of  treatment  in  .so-called  health  resorts  and  in  private 
practice  under  ordinary  conditions  with  those  of  the  sanatorium 
treatment.  These  results,  equally  good  in  whatever  country  the 
institution  exists,  are  the  best  plea  for  their  universal  establishment. 

But  before  entering  into  the  subject  of  the  treatment  proper,  we 
must  review  the  subject  of  climato-therapy  and  arrive,  if  possible, 
at  some  conclusions  as  to  the  value  of  this  or  that  region  in  the 
treatment  of  tuberculous  invalids. 

There  is  hardly  any  subject  on  which  more  has  been  written 
than  on  the  climato-therapy  of  pulmonary  tuberculosis.  There 
is  still  a  vast  diversity  of  opinion  as  to  the  respective  merits  of 
what  are  still  sometimes  called  specific  climates  for  consumptives  ; 
but  the  number  of  phthisio-therapeutists  who  consider  even  the 
best  and  most  suitable  climate  of  .secondary  importance,  and  the 
hygienic  and  dietetic  treatment,  preferably  in  a  closed  establish- 


'  Contrary  to  llie  custom  of  m.iiiy  Knglish-spcakiiig  people,  especially  in  the  United 
.States,  I  call  these  estahlishnifnls  SaiKitoria,  ami  not  Suitilariii.  'I'lie  former  (sana- 
torium), from  siiiiiirf,  to  heal,  gives  a  belter  ec|uivalent  to  the  German  "  lleilanstalt," 
the  word  used  by  the  originator  of  this  system  (Hrehmer).  .Secondly,  the  ^vord  "  sani- 
tarium," from  siiiii/iis,  hcallh,  is  usually  employed  to  designate  a  place  considered  simply 
as  especially  healthy — a  favorite  resort  for  convalescent  patients. 

200 


CLIMATO-THERAPY    IN   PULMONARY   TUBERCULOSIS. 


201 


ment,  or  under  constant  medical  supervision  in  congenial  sur- 
roundings, the  all-important  factor,  is  constantly  increasing.  I  do 
not  deny  the  beneficial  influence  of  certain  climatic  conditions  on 
the  various  forms  of  phthisis;  but,  with  all  defe.ence  to  the  opinion 
of  others,  I  do  not  believe  that  there  exists  any  climate  with  a  specific  ^'spedfic°' 
curative  quality  for  any  form  of  pulmonary  tuberculosis.  Climate  can 
only  be  considered  a  more  or  less  valuable  adjuvant  in  the  treatment 
of  consumption,  but  not  a  specific.  A  tuberculous  patient  of  the  ir- 
ritable pyrexial  type,  with  much  tendency  to  nasal  and  bronchial 
catarrhs,  will  often  do  better  in  a  warm  climate  with  little  elevation, 
such  as  Southern  California,  Southern  Arizona,  New  Mexico,  West- 
ern Texas,  Florida,  etc.,  in  the  United  States  ;  Jersey  and  Sidmouth 
in  England  ;  V  a  and  Hyeres  in  France;  San  Remo  in  Italy,  etc. 

To  higher  altitudes,  such,  for  example,  as  Davos  and  St.  Moritz- 
dorf  in  Switzerland,  or  the  mountains  of  Colorado,  Montana,  Utah, 
and  Wyoming  in  the  United  States,  may  safely  be  sent  early  cases 
with  no  throat  complications,  persons  with  a  chest  badly  developed 
either  by  transmission  of  a  phthisical  predisposition  or  fault  of 
development,  and  all  ordinary  cases  of  phthisis.  They  are  most 
likely  to  be  benefited  in  such  climates.  Weber's  classification  Weber's 
seems  to  be  the  most  correct.  In  his  Croonian  lectures  (1885)  heuon. 
classes  the  following  cases  as  those  for  which  higher  altitudes  are 
unsuitable:  (i)  Consumptive  persons  belonging  to  the  erethic  type, 
whether  the  affection  is  early  or  advanced ;  (2)  phthisis  in  a  very 
advanced  stage;  (3)  phthisis  complicated  with  extensive  emphy- 
sema; (4)  phthisis  complicated  with  albuminuria  ;  (5)  phthisis  com- 
plicated with  di  :,ease  of  the  heart ;  (6)  phthisis  with  ulceration  of 
the  larynx  ;  (7)  phthisis  with  rapid  progress  and  constant  pyrexia  ; 
(8)  phthisis  with  great  loss  of  substance ;  (9)  phthisis  with  consider- 
able empyema;  (10)  phthisis  in  persons  who  cannot  sleep  or  eat  in 
high  elevations,  or  who  feel  constantly  cold. 

As  an  intermediate  altitude  of  between  two  and  three  thousand 
feet,  Fletcher  Ingals  recommends  some  portions  of  Dakota,  Ne- 
braska Minnesota,  the  Adirondack  Mountains,  and  those  of  Vir- 
ginia, North  Carolina,  and  Tennessee,  to  which  I  would  wish  to  add 
the  region  about  Liberty  in  Sullivan  County,  N.  Y.,  as  especially 
suitable  for  phthisical  patients  in  summer.  As  typical  winter  climates 
he  mentions  Arizona,  .Southern  California  (among  the  foot-hills  as 
far  as  possible  from  the  ocean).  Southern  New  Mexico,  South 
Carolina.  Georgia,  and  Texas. 


'  ' 


n  f, 


h1-3; 


4 


202 


PULMONARY   TUBERCULOSIS. 


Climatic 
idiosyn- 
crasies. 


Choice 
between 
warmer 
anil  colder 
climates. 


Besides  this  selection  of  climates  to  suit  the  respective  forms  of 
pulmonary  phthisis,  there  are  to  be  considered  what  I  would  like 
to  call  climatic  idio.syncrasies  among  tuberculous  patients.  Of  two 
patients  with  seemingly  the  same  temperament  and  at  about  the 
same  stage  of  the  disease,  one  feels  best  and  makes  most  rapid  road 
to  recovery  in  one  of  the  Mediterranean  places  or  Southern  Cali- 
fornia ;  while  the  other,  who  had  also  been  sent  to  such  places, 
apparently  would  have  died  had  he  not  left  there  in  time  and  gone 
to  Davos  or  Colorado,  or  some  other  resort  of  high  altitude.  I 
know  of  patients  who  got  well  at  the  Adirondacks  and  felt  badly 
at  Liberty,  and  vice  versa ;  both  places  are  in  the  State  of  New 
York,  and  their  climatic  conditions  differ  very  little.  Some  patients 
do  well  in  island  and  coast  climates  ;  others  improve  greatly  on  a  sea- 
voyage.  While  it  may  be  safely  said  that  in  the  majority  of  cases 
any  climatic  change  will  do  good,  too  much  travel  should  be  dis- 
couraged. To  send  a  patient  away  from  home  in  the  advanced 
stage  of  phthisis  has  always  seemed  to  me  cruel  and  useless,  it 
nearly  always  hastens  a  fatal  termination,  which  is  the  sadder  since 
it  takes  place  among  strangers  and  away  from  home.  Those  desir- 
ing to  benefit  by  climatic  changes  should  travel  to  warmer  climates 
in  fall  and  to  colder  ones  in  spring  ;  thus  the  acclimati/;i.tion  of  the 
consumptive  individual  will  be  more  easily  accomplished. 

As  to  the  choice  of  a  warmer  or  colder  clime  for  a  cure,  Fletcher 
Ingals '  may  be  right  in  .saying  that  patients  who  feel  better  in  cold 
weather  should  be  sent  to  a  comparatively  cold  climate  ;  those  feel- 
ing better  in  summer,  to  warmer  regions.  But,  in  spite  of  excel- 
lent works  in  phthisio-climato-therapy,  such  as  Weber's,''  de  la 
Harpe's,^  and  Solly's,*  our  present  knowledge  of  the  subject  is  still 
limited,  and  opinions  as  to  the  best  method  of  classifying  climates 
as  to  their  respective  merits  in  phthisio-therapy  differ  vastly.  If  I 
should  be  asked  to  express  an  opinion  on  the  subject,  I  would  say 
the  best  climate  for  a  consumptive  is  the  one  where  the  atirothera- 
peutic  portion  of  the  hygienic  and  dietetic  treatment,  as  understood 
to-day  by  the  modern  phthisio-therapeutists,  can  be  carried  out 
most  easily  and  most  persistently ;  or,  in  other  words,  the  best  cli- 


-' 


'  Ingals,  "  Diseases  of  the  Chest,  Throat,  and  Nasal  Cavities." 
'Weber,  Hermann,  "  Cliinatherapie.'' 

'  De  la  llarpe,  "  I'ornuilaire  des  Stations  d'lliver  et  des  Stations  d'litc." 
*  Solly,  "  Medical  Cliniutology." 


CLIMATO-THERAPY    IN    PULMONARY   TUBERCULOSIS. 


203 


mate  for  a  consumptive  is  the  one  which  permits  him  to  remain 
out-doors  more  and  longer  at  a  time  than  anywhere  else.  But  since 
an  ideal  climate  cannot  be  obtained  everywhere  and  will  not  be 
within  the  reach  of  everybody,  the  best  thing  to  do  is  to  get  as  near 
these  conditions  as  possible,  and  preferably  at  not  too  great  a  dis- 
tance from  home.  Places  where  pure,  dry  atmosphere  and  some 
elevation,  with  protection  from  winds,  can  be  had,  abound  more  or 
less  in  all  countries. 

I  cannot  conclude  this  short  review  on  cHmato-therapv  in  re- J^fsuits  in 
gard  to  pulmonary  tuberculosis  without  mentioning  a  most  im-<^''"'»'"." 
portant  fact  which  has  been  very  little  regarded  up  to  this  date 
in  our  text-books  on  climatology.  I  refer  to  the  relative  dura- 
bility of  cures  obtained  in  different  climes.  I  know  from  per- 
sonal observation  of  quite  a  number  of  cases  that  cures  of  pul- 
monary tuberculosis  effected  in  our  home  climates,  which  are,  in 
the  average,  not  considered  as  especially  favorable  to  this  class 
of  sufferers,  have  been  more  lasting  and  more  assured  than  cures 
obtained  in  more  genial  climes  away  from  home.  In  these  obser- 
vations I  do  not  stand  alone,  for  such  men  as  v.  Leyden,  Gerhardt, 
V.  Ziemssen,  Dettweiler,  Naunyn,  Frankel,and  Walthers'  have  had 
the  same  experience.  Of  what  vast  importance  these  facts  are  in 
relation  to  the  social  problem  of  tuberculosis  and  the  treatment  of 
the  tuberculous  poor,  we  will  see  in  chapter  xxv,  where  these  sub- 
jects will  be  dealt  with  more  at  length. 


'  "  Tlie  Practitioner, "  Tuberculosis  number,  London,  1898,  p.  670. 


1?.. 


^if 


CHAPTER    Xr. 

DESCRIPTION  OF  AN  IDEAL  SANATORIUM  FOR  THE 
TREATMENT  OF  TUBERCULOUS  PATIENTS. 


What  locality  should  be  chosen  for  the  establishment  of  a  sana- 
torium where  all  classes  of  consumptives  should  be  received, 
benefited,  and  the  largest  possible  number  cured?  Thoroughly 
disbelieving  in  the  specific  curative  quality  of  any  climate,  I  should 
place  a  sanatorium  where  it  can  do  the  most  good  to  the  largest 
number.  When  we  consider  the  vastly  important  social  and  eco- 
nomical questions  which  the  modern  phthisio-therapeutist  must 
take  into  consideration,  I  cannot  help  declaring  my  firm  belief  that 
it  is  essential  to  the  majority  of  tuberculous  patients  to  be  treated 
and  cured  in  the  same  or  nearly  the  same  climate  where  they  will 
have  to  live  and  work  after  their  restoration  to  health. 
i-ocaiinn.  I  would,  therefore,  placc  the  sanatorium  for  consumptives  within 
easy  reach  of  a  large  centre  of  population,  at  no  greater  distance 
than  from  three  to  five  hours  by  rail.  It  should  be  in  a  region 
known  for  its  relative  purity  of  atmosphere,  where  there  is  freedom 
from  all  miasmatic  and  malarial  influences,  and  where  the  patho- 
genic microbes  are  only  found  in  negligible  ([uantities.  If  possible, 
it  should  be  where  the  extremes  of  temperature  are  not  too  pro- 
nounced, and,  if  the  region  is  a  mountainous  one,  at  an  altitude  of 
from  one  thousand  to  fifteen  hundred  feet.  The  site  should  be  a 
pleasant  one,  with  a  southern  exposure  and  protecteu  from  cold 
winds  by  higher  mountains  or  woodlands  (pine-woods  should  be 
given  the  preference).  The  ground,  of  course,  should  be  dry  and 
porous.  Rut  that  all  these  conditions  are  not  necessary  has  been 
proved  in  institutions  which  have  neither  the  advantages  of  a  favor- 
able climate  nor  a  high  altitude.  There  exists  in  Scotland  an  estab- 
lishment devoted  to  the  treatment  of  consumption,  known  as  the 
"Victoria  Hospital  of  Edinburgh  "  (at  Craigleith).  When  I  visited 
it,  in  September,  1894,  it  had  only  just  opened,  and  up  to  the  31st 
of  May,  1895,  sixty-five  patients  had  been  already  under  treatment, 

204 


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AN    IDEAL  SANATORIUM. 


205 


with  satisfactory  results.'  What  is  possible  in  Scotland  with  its 
rigorous  climate  is  possible  anywhere  else.  In  the  United  States  I 
know  of  two  institutions  located  but  a  few  miles  from  two  of  the 
largest  cities,  and  the  results  obtained  are  certainly  most  remark- 
able, for  there  are  no  special  climatic  advantages  claimed  for  either 
of  them.  Both  locations  are  exposed  to  the  extreme  heat  as  well 
as  to  the  severe  cold  so  frequently  experienced  in  the  Eastern  cities 
of  the  United  States.  I  refer  to  Sharon  Sanatorium,  near  Boston, 
and  the  Chestnut  Hill  Hospital  for  Consumptives,  near  Philadel- 
phia. 

If  I  had  to  choose  between  sending  a  patient  to  what  is  usually 
considered  an  ideal  specific  climate,  but  where  he  would  live  as  in 
an  ordinary  health  resort,  or  keeping  the  patient  home  in  a  fairly 
pure  atmosphere  and  applying  the  hygienic  and  dietetic  treatment 
under  constant  medical  supervision,  I  should  choose  the  latter 
method  of  treatment,  and  think  the  patient  had  a  far  better  chance 
of  recovery. 

In  a  very  elaborate  work  Blumenfeld  ^  has  eiven  the  results  ofinfluence 
his  daily  observations,  throughout  the  year,  of  the  influence  of  the  weather  on 
various  meteorological  changes  exerted  on  the  condition  of  a  large  "ves. 
number  of  phthisical  patients.  His  conclusions  prove,  what  Dett- 
weiler  has  been  preaching  for  the  last  twenty  years,  that  tempera- 
ture, atmospheric  pressure,  and  humidity  scarcely  influence  the 
condition  of  the  consumptive.  The  only  really  dangerous  thing 
such  patients  need  to  guard  against  is  strong,  penetrating  wind. 
Dr.  H.  Weber*  expressed  himself,  at  the  Tenth  International  Med- 
ical Congress,  in  the  following  terms :  "  Die  Behandlung  der 
Schwindsucht  ist  iiberall  moglich  wo  fiir  reine  Luft,  passende 
Nahrung  und  massig  graduirte  Bewegung  gesorgt  werden  kann." 
(The  treatment  of  consumption  is  possible  wherever  there  is  pure 
air,  wherever  appropriate  food  can  be  procured,  and  wherever 
moderate  graduated  exercises  can  be  instituted.)  Von  Leyden, 
Kretschmar,  Dujardin-Beaumetz,  Cantani,  and  other  members  of 
the  congress  expressed  themselves  in  a  similar  way. 


'  riiilip,  R.  \V.,  " 'llie  Victoria  Hospital  for  Consumption,  Edinburgh:   Its  Rise  and 
Outlook."     "  Edinb.  Hosp.  Reports,"  1S95. 

-  niiimenfeid,  "  CIkt  den   Einlluss  mcfeorologischer  Vorgilnge  auf  den  Vcrlauf  der 
bacilliiren  Lungenscliwindsutlil." 

'  "  Verhandiungen  des  X.  Internal.  Congresses,"  lid.  11,  Abtlieilung  5. 


.1 


m\ 


206 


PULMONARY  TUUEKCULOSIS. 


If 


. 


AN    IDEAL   SANATORIUM, 


i07 


The  next  question  to  be  considered  would  be  the  choice  of 
buildin<^s  and  their  mode  of  construction.  Whicli  plan  would  it 
be  best  to  adopt — the  European  system,  in  which  they  house  as 
many  as  seventy-five  to  one  hundred  patients  under  one  roof,  or 
the  American  cottage-system,  with  no  more  than  from  four  to  eight 
in  each  cottage  ?  To  make  so  large  an  aggregation  as  one  finds  in 
some  of  the  European  institutions  seems  certainly  not  a  good  plan, 
since  the  hygienic  measures  are  almost  sure  to  suffer  in  such  a 
liouse.  On  the  other  hand,  the  cottage  system,  while  it  may  be 
the  ideal  for  some  diseases,  is,  on  the  whole,  not  the  most  desirable 
for  a  sanatorium  for  consumptives.  The  constant  medical  super- 
vision— one  of  the  most  important  features  in  the  sanatorium 
treatment — can  hardly  be  carried  out  in  a  village  of  twenty  or  thirty 
small  cottages  several  hundred  feet  apart,  not  to  mention  the 
increased  expense  such  a  system  involves. 

In  visiting  the  numerous  institutions  I  endeavored,  by  taking 
comparative  notes,  to  form  a  plan  of  what  would  seem  an  ideal 
sanatorium  for  the  treatment  of  tuberculous  patients  in  all  .stages, 
and  under  varied  climatic  conditions,  and  adaptable  to  nearly  all 
localities.  I  conveyed  my  ideas  to  my  friend,  Mr.  John  Van  Pelt, 
formerly  of  the  "  Ecole  des  Beaux  Arts  "  of  Paris,  now  Assistant 
Professor  of  Architecture  at  Cornell  University  in  Ithaca,  N.  Y.,  with 
instructions  to  draw  the  plans  necessary  to  illustrate  my  conception 
of  an  ideal  sanatorium  for  the  treatment  of  patients  suffering  from 
pulmonary  tuberculosis.  He  carried  out  my  ideas  most  faithfully, 
and  I  here  show  photographs  of  the  general  view,  the  general  plan, 
the  detailed  plan  of  the  first  story  of  one  of  the  pavilions,  and  a 
drawing  of  the  corner  of  the  veranda,  with  an  adjustable  chair  for 
the  rest  cure. 

As  will  be  seen,  I  have  adopted  a  plan  between  the  European 
and  the  American  ;  in  other  words,  the  large  pavilion  .system. 
Three  pavilions,  each  accommodating  about  twenty  patients,  are 
united  by  galleries  one  hundred  feet  long,  which  serve  for  promen- 
ades on  rainy  days.  Behind  the  central  building  are  situated  the 
winter-garden,  dining-room,  kitchen,  and  the  administration 
building,  all  connected  by  covered  passages.  At  some  little 
distance  ve  find,  to  the  right  and  left,  two  medium-sized  houses, 
one  serving  as  a  residence  for  the  medical  .staff,  the  other  as 
a  place  where  visitors  or  the  friends  of  the  patients,  desiring  to 


ii 


4\ 

'"ft**  I 


m 


208 


PULMONAKY   TUBKRCULOSIS. 


be  near  them,  may  reside.  At  about  two  liundred  and  fifty  feet 
from  the  main  building,  to  the  left,  is  a  paviHon  for  the  purpose  of 
I'nviiionfor  isolatintr  patients.  The  necessity  of  such  a  precaution  was  shown 
me  when,  on  visiting  one  of  the  sanatoria  in  Switzerland,  I  learned 
that  a  short  time  before  a  case  of  scarlatina  had  been  discovered 
among  the  inmates  of  the  one  existing  building,  and  as  a  consequence 
everybody  who  could  had  fled.  Besides,  even  among  the  ordinary 
pulmonary  invalids,  the  occasion  for  the  need  of  isolation  may 
arise.  (In  cases  of  gangrene,  temporary  insanity,  etc  ,  a  separate, 
smaller  pavilion  will  be  indispensable.)  On  the  opposite  side  of 
the  other  buildings,  at  a  considerable  di.stance,  is  situated  the  recre- 


Fic.  66.— I'l.AN  (IF  THK  First  Story  ok  One  ok  thk  I'avm  ions. 


ation  pavilion,  constructed  so  that  two  sides  are  always  entirely 
open.  The  closed  sides  can  be  changed  according  to  the  direction 
of  the  wind.  The  rest  of  the  buildings  are  houses  for  the  gardener 
and  stables  for  the  horses,  etc. 

In  front  of  the  pavilions,  on  the  south  side,  is  the  park,  with  its 
turning  kiosks,  sun-bo.xes,  pr^Jated  paths,  benches,  etc.  On  the 
first  floor  of  each  pavilion  are  fourteen  comfortable,  well-lighted, 
well-ventilated  sleeping-rooms  for  the  patients,  with  two  more 
rooms  for  the  nurses  ;  also  the  toilet-rooms,  etc.  On  the  ground- 
floor  are  the  sitting-rooms,  library,  parlor,  consultation-rooms,  and 


1 


AN    IDKAr.   SANATORIUM. 


209 


the  room  necessary  for  the  hydrothcrnpeiitic  applications,  and 
als(j  several  bedrooms  for  patients.  The  verandas,  eacli  135  feet 
lonj;  and  15  feet  wide,  extend  aion^  the  len^'th  of  tlic  pavilions; 
they  are  protected  by  a  roof  made  partly  of  fjlass,  provided  with 
curtains,  and  arrani^ed  to  make  the  prolonj^ed  stay  of  the  pul- 
monary invalid  as  pleasant  as  possible;  for  it  is  here  that  he  will 
have  to  pass  the  greater  part  of  li<s  time.  For  weaker  patients,  not 
yet  able  to  go  down-stairs  or  take  their  rest  cure  on  the  veranda, 
there  is  ample  room  to  place  a  lounge,  or  even  a  bed,  on  the 
balcony  opening  directly  from  the  rooms. 

Resides  the  ordinary  hygienic  precautions  and  modern  installa-Simiiary 
tions  in    regard  to  plumbing,  heating,  ventilation,  water-supply, "'""s-""' 
electric  lights,  electric  fans   in    dining-rooms,  sitting-rooms,  etc., •'.«"'»*' 
all    angles    throughout   the  house   are    rounded    to    prevent   tiie 
accumulation  of  dust.     The  walls  are  painted  so  that  they  may  be 
easily  disinfected  ;  the  floors  are  of  hard  wood  and  may  be  easily 
mopped,  as  sweeping  or  raising  dust  is  absolutely  forbidden  in  a 
well-conducted  sanatorium. 

In  large  buildings  where  many  invalids  congregate,  of  whom 
some  may  even  be  helpless  at  times,  great  precaution  should  be 
taken  to  prevent  possible  accidents  by  fire.  There  should  be  large 
staircases  and  hallways,  lighted  ail  night,  a  sufficient  number  of 
exits  and  well-kept  fire-escapes,  and,  besides  the  ordinary  firehose 
on  each  floor,  portable  fire-extinguishers  should  be  distributed 
throughout  the  buildiuj^.  Rut  equally  important  is  the  training  of 
the  nurses  and  other  help  for  such  emergencies.  During  my 
service  at  the  Falkenstein  Sanatorium  I  witnessed  a  (ew  drills  of 
the  sanatorium  fire-brigade,  composed  exclusively  of  the  personnel 
of  the  institution.  The  alarm  for  the  drill  is  given  unknown  to 
the  nurses  and  help,  but  all  patients  were  previously  notified  that 
at  a  certain  time  the  fire-alarm  bell  would  be  sounded.  These 
drills  serve  not  only  as  a  pleasant  diversion  to  the  patients,  who 
could  calmly  look  on  upon  the  interesting  feats  performed  by  the 
firemen,  but  they  also  serve  to  give  them  a  feeling  of  security. 

Since  it  is  the  duty  of  the  .nodern  phthisio-therapeutist  and  Pjmcction 
sanitarian  to  avoid  by  all  possible  precaution  the  tuberculous  in- !"'">. 
fection   of  man  through  beast,  he  must  also  necessarily  institute""""*!'' 

^  '  ■'  man. 

measures  to  protect  the  beast  from  tuberculous  infection  through 
man.     The  necessity  of  such  precaution  was  strongly  impressed 
upon  me  when  visiting  an  institution   in  a  State  where  much  is 
14 


I 


1 


■  t 


It 


i  If 

i  •'%' 


lif 

m 


">^' 


1^1 


Sift"; 


'mi 


2IO 


PULMONARY   TUBERCULOSIS. 


done  in  the  direction  of  prophylaxis.  This  institution  receives 
nearly  two  hundred  patients  annually,  the  majority  being  con- 
sumptives. 

The  following  is  one  of  the  rules  conspicuously  posted  through- 
out the  house:  "  Patients  must  at  all  times,  when  in  the  institution 


I'lu.  6;.— CoKNKR  OF  Vkkanda.  wnii  Auji  STAiii-K  Chair  for  Ri:st  Curk, 


I 


or  on  the  verandas,  expectorate  in  the  sputa-cups  provided.  They 
must  never  expectorate  in  the  sinks,  wash-basins,  closets,  or  on  the 
floor,  or  in  their  handkerchiefs."  Outside  the  institution  the 
patients  are  not  restricted  ;  they  may  expectorate  wherever  they 
please,  and  I  have  no  doubt  they  do.  I  was  told  that  a  neighbor- 
ing farmer,  who  had  some  time  ago  bought  five  healthy  cows,  had 


AN    IDEAL  SANATORIUM. 


211 


theiii  tested  recently,  with  the  result  that  three  were  found  tuber- 
culous. It  seems  thus  to  me  unwise  to  have  the  dairy  on  or  too 
near  the  premises  of  a  sanatorium  for  consumptives.  There  will 
He  occasionally  a  careless,  unconscientious  patient  in  all  institutions 
of  this  kind  who  may  expectorate  on  the  surroundinj^  grounds, 
where  animals  are  likely  to  come  in  contact  with  the  sputum  on 
the  grass. 

In  an  institution  for  the  treatment  of  consumptives  there  will 
be,  of  course,  the  strictest  precautions  concerning  the  tuberculous 
e.Kpectorations  and  other  secretions.  We  have  described  at  length 
in  chapter  iv  (pp.  38-43)  the  various  spittoons  which  should  be  in 
use  in  such  a  sanatorium.  They  should  be  the  elevated  spittoons 
in  niches  or  on  stands ;  the  small,  mug-like  spittoon,  which  the 
patients  may  use  during  their  rest  cure ;  and,  finally,  the  pocket- 
flask.  Of  all  these  there  should  be  two  sets,  so  that  they  are 
never  wanting  when  one  set  is  being  cleaned  and  disinfected. 

Each  well-regulated  sanatorium  should  have  special  facilities  forManase- 

,..-.  ,.  iri  1*11  111  1  r        nient  ami 

disinfecting  spoons,  knives,  and  forks,  which  should  be  done  after  discipline 

_,  .  .  ill  a  Sana- 

each  meai.  At  the  ralkenstein  Sanatorium  an  especially  con- tonum. 
structed  sterilizinp;  apparatus  is  used  for  this  purpose.  All  table- 
linen  should  be  steeped  In  boiling  water  before  being  given  to  the 
laundry,  and  the  same  precaution  should  be  e.xercised  with  the 
bed-  -ind  private  linen  of  the  patients.  The  rooms  in  an  ideal  sana- 
torium for  consumptives  should  be  submitted  to  a  thorough  dis- 
infection by  formaldehyde  gas  at  regular  intervals,  and  not  only 
after  the  death  or  removal  of  a  patient.  A  simple  and  thorough 
method  of  room  disinfection  we  described  on  page  58. 

While  it  will  not  be  possible  to  enforce  a  rule  concerning  the 
toi''.  .s  of  ladies  in  a  sanatorium,  the  wearing  of  trailing  dresses 
should  not  be  permitted,  and  the  gentlemen  of  the  institution 
should  not  be  allowed  to  smoke  inside  the  buildings. 

The  discipline  in  an  ideal  sanatorium  for  the  treatment  of  con- 
sumptives need  not,  of  necessity,  be  too  severe,  but  all  those  rules 
and  regulations  enacted  in  the  interest  of  the  patient  and  his  sur- 
roundings should  be  religiously  obeyed.  A  patient  should  not 
absent  himself  from  the  .sanatorium  without  permission  from  the 
doctor. 

It  mny  not  be  amiss,  in  speaking  of  an  ideal  sanatorium,  also  to 
say  a  few  words  regarding  the  ideal  management.  Some  of  the 
European  institutions  are  managed  in  two  departments,  presided 


!l-   I 


ili: 


212 


PULMONARY   TUBERCULOSIS. 


p.. 


*  '^■•1 


1  I 

irfl     I 


over  by  a  medical  director  and  a  general  superintendent,  respect- 
ively. In  some  the  former,  in  others  the  latter  would  be  con- 
sidered the  superior  in  cases  of  conflict.  While  visiting  the  Euro- 
pean sanatoria  it  has  been  my  lot  to  witness  such  a  conflict  between 
the  two  heads  of  a  sanatorium,  and  the  lesson  I  learned  therefrom 
was  most  valuable.  In  a  sanatorium  for  the  treatment  of  con- 
sumptives the  medical  director  should  always  be  the  final  court 
of  appeal,  as  well  in  the  general  as  in  the  medical  affairs  of  the 
institution. 


PI!' 


CHAPTER  XII. 


AEROTHERAPEUTICS,  REST  CURE,  AND  EXERCISES. 


The  main  object  of  actotherapeutics  is  to  oblige  the  patient  to 
live  as  much  as  possible  in  the  open  air.  A  patient  arriving  at  a 
sanatorium  and  having  a  high  temperature — for  example,  above 
102°  F. — should  be  left  in  bed  and  moved,  during  the  day,  toward 
the  open  window  or  on  to  the  balcony.  When  his  temperature  goes 
down  he  is  allowed  to  begin  his  rest  cure  (Liegekur  of  Dettweiler) 
on  the  veranda  on  a  lounge,  steamer-chair,  or,  better  yet,  on  a 
reclining-chair  especially  constructed  for  the  purpose,  such  as  I 
illustrate  on  page  210.  The  back  of  this  chair  can  be  given  any 
desired  inclination. 

It  is  needless  to  say  that  a  patient,  especially  one  coming  from 
a  sick-room  in  a  large  city,  must  only  be  submitted  gradually  to 
the  exhilarating  influence  of  a  constant  sojourn  in  the  open  air; 
but  the  endurance  at  which  one  may  arrive  in  this  respect  is 
wonderful.  In  Falkenstein  the  patients  remain  out-of-doors  on 
their  chairs  from  seven  to  ten  hours  a  day  all  the  year  round,  in 
spite  of  fog,  rain,  wind,  snow,  and  even  with  the  thermometer  at 
12°  C.  below  zero,  and  often  no  sunshine.  Dr.  Andvord,  of  Ton- 
saasen,  Norway,  wrote  me  that  l.e  leaves  his  patients  on  their 
chairs,  wrapped  up  in  furs,  from  five  to  nine  hours  a  day  at  a  tem- 
perature of  — 25°  C. 

It  is  to  this  prolonged  stay  in  the  open  air  (Dauerluftkur  of  the 
Germans)  that  the  marvelous  results  obtained  in  these  institutions 
may  be  attributed.  Besides  the  rest  cure  in  the  fresli  air,  there  is 
moderate  exercise  on  gradated  walks  in  the  garden — that  is  to  say, 
on  paths  varying  in  inclination  from  one  foot  in  three  hundred  to 
one  in  sixty.  At  night  the  patient  sleeps  with  his  window  open, 
rain  or  shine,  warm  or  cold  ;  wide-open  in  summer,  less  so  in 
winter.  The  only  excuse  for  closing  the  window  migiit  be  a  very 
strong  wind  or  a  thick  fog.  A  consumptive,  if  he  wishes  to  get 
well,  should  live  every  moment  of  his  existence  in  the  purest  and 
freshest  air  possible.     During  the  rest  cure  on  the  reclining-chair 

213 


Precaution 
(liiiiiiK  the 
rest  cure  in 
tlie  opuii 
uir. 


i 


AW 


m    ( 


'^i 


' 


I 


.1 


I     ? 

■  h 


214 


PULMONARY   TUBERCULOSIS. 


the  patient  is  allowed  to  read  or  write,  and  is  made  as  comfortable 
as  possible.  The  main  point  to  be  attained  is  an  almost  complete 
muscular  relaxation,  in  order  to  economize  and  store  up  strength 
and  reduce  the  fever.  When  on  their  chairs  on  the  veranda, 
patients  should  always  be  covered  with  blankets  or  lap-robes,  in 
accordance  with  the  season  ;  furs  in  winter  are  indispensable. 
There  is  always  an  attendant  attached  to  the  service  to  see  that 
patients  do  not  become  uncovered  while  asleep. 

Short  naps  after  Uieals  are  allowed,  but  they  should  not  exceed  ten 
minutes  or  so.  Consumptives  are  so  apt  to  perspire  when  asleep 
any  length  of  time,  and  especially  when  warmly  dressed,  that  this 
might  be  the  cause  of  their  catching  a  severe  cold.  The  patients 
watch  over  each  other  alternately  to  see  that  they  do  not  sleep  too 
long.  Patients  are  warned,  when  taking  their  rest  cure,  never  to 
let  the  sun  shine  directly  on  their  heads.  Congestion,  headache, 
and  other  troubles  often  follow  if  this  precaution  is  neglected. 

The  good  results  which  are  obtained  by  the  rest  cure  in  the  open 
air  are,  indeed,  at  times  wonderful;  and  still,  with  all  due  reverence 
for  the  great  originator  of  the  "  Liegekur,"  the  distinguished 
phthisio-therapeutist,  Dettweiler,  it  is  not  without  danger  as  it  is 
practised  in  many  European  sanatoria.  To  have  a  patient  lie  on  his 
back  for  three  or  four  hours  at  a  time  without  rising,  and  repeating 
this  two  or  three  times  during  the  day,  seems  to  me  dangerous,  for 
it  facilitates  hypostatic  congestion  of  the  lungs.  I  know  of  several 
cases  where  this  condition  has  been  brought  about  by  thus  remain- 
ing too  long  in  the  recumbent  position.  There  is  another  reason 
why  I  do  not  favor  this  remaining  undisturbed  for  hours  on  the  re- 
clining-chair.  The  local  temperature  of  the  back,  being  in  constant 
contact  with  the  warm  cushions,  will  cause  this  part  to  become  more 
sensitive  to  temperature  changes  than  it  had  been,  perhaps,  ever 
before  ;  and  it  seems  to  me  easy  to  explain  thereby  why  patients  in 
institutions  where  the  cure  is  practised  as  just  described  always 
complain  of  cold  backs. 

It  is  for  this  reason  that  I  think  respiratory  exercises  should  be 

The    patient 

If 

^ipHKiit  po-this  tires  him  too    much    he  may,   however,   simply  change    his 

reclining  position  for  the  straight  sitting  position,  raise  his  arms 

ani^  go  through  the  first  and  second  respiratory  exercises  a  few 

ti.iies.     Should  even  the  raising  of  the  arms  tire  him,  he  may  go 


Value  of 

aUeriiating  .   ,         . 

the  "Liege- made   to   alternate    with  the  rest  cure    out-doors. 

kur"  with      ,  ,  ,       .  ,  1      tr  1  11 

respiratory  should  risc  evcry  hour,  or  half-hour,  to  take  these  exercises. 


exercises  111 

iiprigl 

sitioti 


AEROTHERAPEUTICS,    REST   CURE,   AND   EXERCISES. 


'•      I 


through  the  exercise  by  simply  moving  his  shoulder-jomts  upward 
and  backward,  which  is  the  exercise  prescribed  for  pulmonar}*  in- 
valids when  the  raising  of  the  arms  is  not  practicable  (p.  85),  My 
experience  has  taught  me  that  these  exercises  are  of  value  in 
nearly  all  cases  except  in  acute  inflammatory  processes,  m  fretjuent 
active  pulmonary  haemorrhages,  and  whenever  there  is  a  con- 
stant temperature  of  100°  or  more.  I  have  described  in  full, 
and  endeavored  to  illustrate,  my  system  of  breathing  exercises 
in  a  preceding  chapter  on  Preventive  Treatment  (pp.  82-S6J,  As 
I  stated  there,  they  are  alike  beneficial  for  the  predisposed  and 
for  the  patient  with  developed  pulmonary  tuberculosis.  For  the 
latter  a  more  strict  medical  supervision  and  a  more  careful!  gradation 
is,  of  course,  necessary.  It  is  true  that  whenever  there  are  old 
pleuritic  adhesions  these  e.xtra  respiratory  efforts  may  cause  mo- 
ments of  pain  ;  the  patient  must,  however,  bear  in  mind  that  these 
pains  are  not  lasting  and  are  in  reality  salutary,  being  caused  by 
the  loosening  of  the  fibrinous  bands.  By  these  breathing  exercises 
the  respiratory  muscles  become  developed,  the  process  of  haema- 
tosis  more  complete,  and  the  increased  respiratory  function  helps 
to  dissolve  the  mucus  and  makes  cough  and  expectoration  more 
easy.  More  advanced  and  very  weak  patients  must  content  them- 
selves with  deep  but  quiet  respirations  without  movement  of  the 
arms.  Placing  a  pillow  under  the  back  of  these  patients  so  as  to 
realize  somewhat  Sylvester's  position,  employed  when  artificial 
respiration  is  necessary,  will  be  found  a  valuable  adjuvant-  It  is 
interesting  and  pleasing  to  note  how  patients  who  have  been  bad 
breathers  for  years  learn  to  love  these  exercises,  so  that  it  seems 
to  them  they  can  no  longer  live  without  going  through  with  their 
regular  performance  at  stated  intervals. 

There  are  in  the  market  numerous  apparatus  invented  for  the 
purpose  of  performing  certain  alleged  especially  beneficial  respir- 
atory movements.  I  have  experienced  with  several  of  them 
myself  and  had  them  tried  by  patients.  These  trials  resulted  in 
having  abandoned  all  these  mechanical  devices,  finding  that  the 
simpler  the  exercises  and  the  less  exertion  there  is  re^juired,  the 
more  readily  will  the  patient  carry  out  the  instructions  concerning 
them,  and  the  more  efficacious  will  they  prove  in  the  end. 

The  only  instrument  which  seems  to  me  of  real  value  in  stimu- j.^p^^on^.g 
lating  the  desire  to  take  deep  inspiration  is  Professor  Alifred  von  cha!r.'""^" 
Usedom's  "  Athmungs-Stuhl,"  or  breathing-chair.      The  dcscrip- 


n'*  !i 


2l6 


PULMONARY  TUBERCULOSIS. 


tion  of  this  chair  appeared  for  the  first  time  in  the  "  Aerztliche 
Politechnik  "  of  May,  1898.  The  arrangement  of  the  chair  seemed 
to  me  so  ingenious  that  I  had  one  constructed  for  a  patient  who 
was  in  the  habit  of  sitting  and  standing  in  a  bent-over  position 
(Fig.  68\  and  who  needed  a  great  deal  of  reminding  to  take  his 
respi.dtory  exercises.  The  result  of  making  him  sit  on  the  breath- 
ing-chair, instead  of  an  ordinary  one,  has  been  most  gratifying. 
The  main  characteristic  of  the  chair  is  the  movable  back,  suspended 
by  a  cord  at  about  the  height  of  the  middle  of  the  back  (Fig.  69). 


iG.  68.— Usual  .'\TTlTunF  in  an  ORniSARV  Chair 


Fig.  (>9.— Pr()i\  Iskdom's  Brkathing-Chair, 


This  cord  must  be  arranged  loo.se  enough  to  yield  to  forward  and 
backward  movements.  During  inspiration  the  upper  portion  of 
the  back  will  be  pushed  backward,  the  lower  portion  forward. 
During  the  act  of  expiration  the  reverse  process  will  take  place. 
Since  the  two  acts  are  automatic  and  regular,  the  lungs  of  the 
patient  receive  thus  an  energetic  stimulus  to  deep  respiratory 
movements.  I  should  advise  a  number  of  such  chairs  as  necessary 
to  a  complete  equipment  of  a  sanatorium.  In  fact,  considering 
that  the   majority  of  chairs  now  in  use  have  backs  which  rather 


AEROTHERAPEUTICS,    REST   CURE,    AND    EXERCISES. 


217 


tend  to  make  one  sit  in  a  bent-over  position,  I  would  recommend 
this  sort  of  chair  for  more  universal  use,  especially  in  schools, 
colleges,  offices,  etc.  They  would,  no  doubt,  constitute  one  of  the 
factors  in  the  prevention  of  pulmonary  diseases,  and  serve  in  a 
measure  to  overcome  the  so-called  "  habitus  phthisicus,"  so 
characteristic  of  many  consumptives. 

Much  has  been  written  on  the  question  of  exercise  in  the  open  walking 
air  for  pulmonary  invalids.  Brehmer  was  much  in  favor  of  it  and 
as  much  as  possible  of  it  in  order  to  strengthen  the  heart,  and  some 
of  our  American  phthisio-therapeutists  are  of  the  same  opinion. 
Dettweiler  and  his  pupils,  on  the  contrary,  are  opposed  to  it,  ex- 
cept under  restriction  and  the  most  careful  supervision.  The  rest 
cure  on  the  reclining-chairs,  as  above  described,  is  even  now  ad- 
mitted in  the  sanatorium  created  by  Brehmer.  It  seems  to  me 
that  the  wisest  course  to  pursue  would  be  to  consider  each  in- 
dividual case,  and  prescribe  or  forbid  exercises  according  to  the 
condition  and  the  strength  of  the  patient. 

We  have  already  spoken  of  gradated  walks  of  various  inclina- 
tions to  test  the  patient's  strength  in  regard  to  his  climbing  powers. 
The  duration  of  a  promenade  should  be  graduated  with  equal  care. 
One  should  commence  with  a  walk  of  a  few  minutes  until  a  walk  of 
an  hour  or  an  hour  and  a  half  can  be  taken  without  producing 
fatigue.  Wherever  it  is  practicable  these  excursions  should  begin 
up-hill,  so  that  the  return  is  easy.  After  his  promenade  the 
patient's  temperature  should  be  taken.  If  it  exceeds  the  normal 
it  is  an  indication  that  the  patient  has  overtaxed  his  powers. 
Whether  complete  rest  or  simply  shorter  walks  are  then  indicated 
will  be  decided  by  the  variation  of  the  temperature  before  and 
after  exercise.  When  the  temperature  of  the  patient  only  rises 
slightly  in  the  evening  (99°-99jj°  F.),  short  walks  in  the  morning, 
while  in  the  apyretic  state,  may  be  permitted.  A  lasting  tem- 
perature of  100°  F.  or  over  is  an  absolute  contra-indication  to 
exercise.  Tachycardia  should  also  be  considered  as  such.  If  there 
is,  however,  a  chronic  tachycardiac  condition,  absolute  rest  might 
not  be  the  best  policy.  But  these  patients,  more  than  any  others, 
should  be  warned  against  the  slightest  overexertion.  Breathing 
exercises  and  walks  may  be  combined,  the  patient  taking  three  to 
five  of  the  exercises  above  described,  with  or  without  moving  the 
arms,  in  every  150  to  200  steps. 


M 
i''j. 


Descrip- 
tion. 


CHAPTER  XIII. 

THE  PNEUMATIC  CABINET  IN  THE  TREATMENT  OF 
PULMONARY  TUBERCULOSIS. 

In  the  modern  therapeutics  of  pulmonary  diseases  the  pneumatic 
cabinet  takes  its  place  in  importance  immediately  after  general 
aerotherapeutics.  To  the  physicians  who  have  used  it  persistently 
and  studied  its  effects,  it  certainly  has  rendered  valuable  services. 
Still,  I  am  aware  that  it  is  relatively  little  known,  and  thus  it  may, 
perhaps,  not  be  amiss  to  describe  its  construction  somewhat  in 
detail. 

The  pneumatic  cabinet  has  the  form  of  a  tall  safe,  somewhat 
larger  at  the  bottom  than  at  the  top.  Its  door  and  apertures  close 
hermetically.  It  is  large  enough  for  a  patient  to  sit  comfortably 
inside.  The  fr  at  is  composed,  in  part,  of  a  large  plate  of  glass 
through  which  the  operator,  manipulating  the  lever,  watches  the 
patient.  By  a  system  of  valves,  bellows,  and  lever,  compres.sed  or 
rarefied  air  can  be  produced.  An  opening  through  the  frontal 
glass  plate  serves  for  communication  with  the  outside  air,  which 
the  patient  inhales  through  a  rubber  tube.  The  amount  of  in- 
coming air  can  be  regulated  by  the  stop-cock  of  a  faucet.  The 
degree  of  rarefication  or  compression  is  indicated  by  a  manometer 
in  communication  with  the  inside  atmosphere  of  the  cabinet.  I 
append  a  drawing  of  the  pneumatic  cabinet  in  my  possession, 
which  is  the  model  now  used  by  nearly  all  phthisio-therapeutists 
who  employ  this  instrument. 

The  principle  of  the  cabinet  in  the  treatment  of  pulmonary 
tuberculosis  is  to  diminish  the  weight  of  the  atmospheric  pressure, 
which  at  the  sea-level,  under  normal  conditions,  is  about  fifteen 
pounds  to  the  square  inch.  With  the  aid  of  the  cabinet  it  can  be 
reduced  nearly  to  fourteen  pounds  to  the  square  inch. 

The  action  of  the  pneumatic  cabinet  has  been   described  by 

218 


THE  PNEUMATIC  CABINET  IN  PULMONARY  TUBERCULOSIS.  2\g 


many  authors,  such  as  Bowditch/  Fox,^  Houghton,'  Hudson,^  acHoh 
Jensen,"  Ketchum,'  Westbrook,^  Williams,*  and  others.  In  perusing  cahintt. 
the  extensive  literature  on  the  subject  I  found  Piatt's'  exposition 
one  of  the  clearest.  His  experience  concords  with  mine  in  almost 
every  detail.  He  describes  the  action  of  the  pneumatic  cabinet  as 
follows :  "  Such  portion  of  the  thoracic  cavity  as  is  not  occupied 
by  tissue — muscular,  glandular,  the  parenchyma  of  the  lung,  etc. — 
consists  of  air-space  and  blood-space,  and  it  is  obvious  that  the 
increase  in  one  of  these  will  tend  to  the  diminution  of  the  other. 
The  respiration  of  air  at  the  normal  tension  while  the  body  is 
immersed  in  a  rarefied  atmosphere  is,  in  effect,  the  same  as  the 
introduction  of  a  compressed  atmosphere  into  the  air-space  of  the 
lungs  ;  it  will  increase  the  air-space  and  tend  to  diminish  the  blood- 
space,  driving  a  certain  portion  of  the  blood  from  the  lungs  into 
the  general  circulation,  which  is  subjected  to  a  diminished  pressure. 
The  pulmonary  congestion  is  diminished  in  exactly  the  same  way 
as  the  congestion  of  an  inflamed  joint  or  of  an  ulcer  by  bandaging. 
Or,  to  put  it  in  another  way,  the  blood  is  sucked  or  drawn  out 
from  the  lungs  into  the  general  circulation,  as  it  is  sucked  into  the 
space  beneath  a  cupping-glass. 

"This  I  believe  to  be  the  main  action  of  the  cabinet,  the  re- 
duction of  pulmonary  congestion,  and  the  theory  is  practically 
verified  by  our  experience  with  regard  to  blood-spitting  and  bron- 
chial hivniorrhage.  Time  and  again,  patients  have  come  into  the 
office  complaining  of  the  sputa  being  blood-streaked,  and,  almost 

'  V.  \'.  liowditch,  "  Boston  Med.  and  Surg.  Jour.,"  July  l6,  1885  ;  and  "  Journal 
of  the  Anitr.  Med.  Association,"  Aug.  I,  1885. 

2  .Sidney  A.  Fox,  "  A  Report  of  Sixty-nine  Cases  of  I.ung  Disease  Treated  with  the 
rneumatic  Cabinet,"  "New  York  Med.  Jour.,"  June  26,  1886. 

'  A.  F.  Houghton,  "Journal  of  the  Amer.  Med.  Association,"  Xov.  7,  1S85. 

*  E.  Darvin  Hudson,  Jr.,  "  Present  Status  of  the  Pneumatic  Treatment  of  Respira- 
tory Diseases,"  "  Med.  Record,"  Jan.  9,  1886. 

'  Dr.  Jensen,  same  journal  and  date  as  r->r.  Houghton's  article. 

'Jos.  Ketchum,  Fsq.,  "The  Physics  of  Pneumatic  Differentiation,"  "Med. 
Record,"  Jan.  9,  18S6. 

'  Henj.  F.  \Vestbrook,  "Pneumatic  Differentiation,"  "New  York  Med.  Jour.," 
Jan.  26,  1S86. 

*  H.  F.  Williams,  "  Antiseptic  Treatment  of  Pulmonary  Diseases  by  Means  of 
Pneumatic  Differentiation,"  "Med.  Record,"  Jan.  17,  1885  ;  "Pneumatic  Differentia- 
tion," "New  York  Med.  Jour.,"  July  16,  1885. 

'  Isaac  Hull  Piatt,  "  On  the  Practical  Application  of  the  Pneumatic  Cabinet,"  "  New 
York  Med.  Jour.,"  June  26,  1886. 


mi 


i>  li  ■ 


lilt 


I  j 


2  20 


PULMONARY  TUBKKCULOSIS. 


without  a  siiif^le  exception,  the  use  of  the  cabinet  has  relieved  the 
symptom  in  tlie  course  of  a  few  minutes. 

"  In  addition  to  the  effect  it  has  u])on  the  pulmonary  congestion, 
it  undout)tedly  acts  beneficially  in  other  ways.  The  thoracic  gym- 
nastics afforded  by  e.>cpiration  against  increased  resistance  will 
probably    be    of    benefit    to    the    weak-chesteil.      The    increased 


Kk;.  70,— Pnkl'Math;  Caiunkt. 

oxygenation  of  the  blood  will,  doubtless,  improve  the  nutritive 
processes.  Then  the  spray,  if  proper  medicaments  are  used,  may 
be  expected  to  act  beneficially  upon  the  accompanying  bronchitis." 
Quimby,'  who  is,  perhaps,  the  best  authority  on  the  subject  of 
cabinet  treatment  in  pulmonary  tuberculosis, — for  he  has  used  the 
cabinet  longer  and  more   persistently  than  any  other   phthisio- 

'  Quimby,  C.  E.,  "  The  Pneumntic  Cabinet  in  the  Treatment  of  Puhuonary  Phthisis," 
"  Internal.  Med.  Magazine"  for  January,  189J. 


, 


'HI 


THK   I'NKUMATIC   CAlilNKT    IN    rUI.MONAKV   TUIiKKCULOSIS.      221 


ve 
ay 

5. 

of 
he 

io- 


theiapeiitist  I  know  of, — gives  as  the  conclusion  of  a  most  remark- 
able paper  on  this  subject,  rend  before  the  American  Climato- 
logical  Association  in  Richfield  Springs,  N.  Y.,  June  24,  i<S92,  tlie 
following  interesting  table  :  ' 

Rl-:1.ATIU.\S  OK  THK  I'XKUMATiC  CAUINKr  To  THK  DKSlRL'i   TIVE    Q„i,„by's 
FORCES  OF  PULMONARY  I'HTHISIS.  c~'"^l"' 

8IUIIK. 

A.  SrKCiFic. 

1.  Does  not  directly  affect  I.  Tlie  tubercle  Imcilhis. 

2.  Limits  by  rapid  absorption 


T 
H 
E 

C 

A 

1; 

1 

N 

E 

T 


2.   Tubercle  toxine  necrosis. 


B.  Local  and  Mf.(  hank  ai.. 


3.  Diminishes 


By  (n)  absorption  of 
{/i)   removal  of 

4.  Loosens  and  removes 

Thus  ((7)  Reopening 

(/>)  Allaying 

(c )  Restoring 

(t/)  Diminishing 

(e )  Preventing 

( /■)  Minimizing 

5.  Stretches  and  absorbs 


Thus,  Restoring 


I 


3.  Tissue     and    vascular   compression 

from 
(a)  Inllammatory  exudate. 
(/' )  Necrotic  products. 

4.  Alveolar    and    tubular   obstruction, 

causing 
(a )  Collapsed  alveoli. 
(/')  Local  tissue  irritation. 
(r)   Deficient  oxygenation. 
(</)  Septic  decomposition. 
(f)  Systemic  infection. 
( /')  Septic  fever. 

5.  I'leuritic  libroses,  arresting 

111)  Respiration  ■)    ,„  .     , 

),  ;   ...    '  ,    .        .   (Oxygenation). 
(/' )  Circu haioii       \      .">  ■' 


C.   SYSTt.MIC. 


Ci.   Diminishes  and  retards 
l!y  (<;)   Removing 
(/' )   Increasing 


6.   Systemic  malnutrition  from 
(a)  Respiratory  olistructions. 
(i)  Weak  circulation. 


KKLATIONS  OF   THE   PNEUMATIC  CABINET  TO   THE  CON.STRUCTIVE 
FORCES  OF  PULMONARY  PHTHISIS. 


T 
H 
E 

C 
A 
li 
I 

N 
E 

r 


A.  Specific. 


1.  Increa.ses  nutrition  of 

2.  Makes  dynamic 


I''avors  and  moderates 


1.  Tubercular  granulations. 

2.  The  potential  value  of  toxine  (?). 


Local. 
3.    Productive 


depend- 


By  (<; )  Traumatic  increase  of 
(fi )   Removing  obstruction  to 

(c)  Augmenting 

(d)  Increasing 
Stimulates 

By  {(I )   Incre.nsing 

(fi)  Restoring  normal 


C.  SV! 


Stimulates 
By  ((?)  Improving 
(fi  )   Doubling 


inllammntion, 
ing  on 
(<; )    I.ocal  irritation. 
(/')   Freedom  of  circulation. 
((■)   Nutritive  vascular  supply. 
(d)   Lymphatic  absorption. 
Local  tissue  vitality,  depending  on 
(ti)  Circulation. 
(/')   Anator'ical  conditions. 


Genp.al  glandular  activity  from 

(<;)  Circulation. 

(i)  Respiratory  eapacitv. 


^1 


i  jf'i 

n* 

I 

4»' 


"  9i — 


feij 

m 


Itt 


k> ■':■ '  ■ 


22: 


PULMONAKV   TUBERCULOSIS. 


When  I  first  began  to  investigate  the  pneumatic  cabinet  treat- 
ment, I  saw  it  used  as  I  believe  it  is  now  still  used  by  the  majority 
of  physicians.  The  patient  enters  the  cabinet  completely  dressed, 
he  inserts  the  tube  into  his  mouth,  and  the  operator  manipulates 
the  lever  from  five  to  ten  minutes,  retaining  the  manometer  at  the 
height  of  about  an  inch.  The  good  effect  of  this  treatment,  it  seemed 
to  me,  could  be  lieightened  by  some  modifications  whicli  suggested 
themselves  to  me  in  the  course  of  my  own  experience  with  the 
cabinet.  I  have  refrained  from  publishing  these  modifications,  for 
the  simple  reason  that  I  wished  to  see  their  utility  verified  by 
larger  experience.  Now,  after  having  used  the  cabinet  treatment 
with  my  modifications  in  quite  a  large  number  of  cases  in  liospital 
and  private  practice,  and  in  most  instances  for  many  months  at  a 
time,  I  feel  more  prepared  to  publish  the  system  I  have  adopted  in 
connection  with  the  use  of  the  cabinet  in  pulmonary  tuberculosis. 


Fig.  71.— Tube  with  Nosb-.mask. 

Author's  With  the  exception  of  the  very  weakest  and  highly  febrile  cases, 
tiimoftiie  nearly  all  tuberculous  patients  can  take  the  pneumatic  cabinet 
treatment,  treatment.  Before  admitting  my  patients  into  the  cabinet  I  tt  ach 
them  how  to  breathe.  They  must  first  take  a  course  of  respiratory 
exerci.ses,  such  as  I  described  in  chapter  vii,  and  only  after  they  have 
learned  to  use  their  respiratory  muscles  to  the  best  advantage  do 
I  begin  the  treatment,  with  short  seances  at  first.  Any  mechanical 
obstruction  to  proper  breathing  has,  of  course,  been  looked  after 
previous  to  the  commencement  of  the  respiratory  exercises.  Any 
intercurrent  acute  coryza  must  be  attended  to  before  putting  the 
patient  in  the  cabinet.  Besides  the  general  treatment,  these 
coryzas  should  be  treated  locally  by  either  the  application  to  the 
nares  of  a  one  or  two  per  cent,  solution  of  cocaine,  or  by  cleansing 
with  and  spraying  of  liquid  albolene,  benzoinol,  alphasol,  or  other 
mild  antiseptic  solution.  I  insist  upon  proper  breathing  through 
the  nose,  and  the  conditions  neces.sary  thereto,  for  the  reason  that  I 
have  abandoned  the  custom  of  having  the  patient  put  the  rubber 


; 


TlIK    I'NEUMATIC    CAllINET    IN    I'ULMONAKV    TUMKKCUI.OSIS.       223 


breathin^^-tiibe  in  his  mouth.  To  this  end  I  liad  nosc-niasks  con- 
structed, which,  owing  to  the  malleability  of  their  posterior  portion, 
can  be  molded  to  lit  the  form  of  any  nose.  The  patient  either 
holds  the  mask,  pressing  it  to  the  face,  or  it  is  fastened  by  a  strong 
elastic  band  encircling  the  head.  A  little  cotton  or  a  thin  cloth 
placed  between  tlie  nasal  bones  and  the  malleable  portion  of  the 
mask  will  prevent  the  possibility  of  the  outside  air  entering  the 
cabinet.  The  anterior  portion  of  the  mask  is  attached  to  the 
ordinary  rubber  tube,  which,  in  turn,  is  fastened  to  the  cabinet  end 
of  the  faucet.     The  accompanying  drawing  will  illustrate  both. 

I  have  found  this  system  of  natural  breathing  superior  to  mouth- 
breathing,  and  many  of  my  hospital  patients  who  had  been  also 
treated  by  my  predecessors,  but  with  the  mouth-tube,  have  again 
and  again  assured  me  that  they  not  only  liked  the  nose-breathing 
better,  but  that  they  felt  better  after  it  than  when  they  breathed 
through  the  mouth.  They  felt  that  they  got  just  as  mucli  air  into 
their  lungs  as  with  the  old  .system.  I  mention  this  to  answer  the 
objections  which  were  made  by  some  of  my  colleagues  at  the  hos- 
pital, who  claimed  that  the  patient  does  not  receive  enough  air 
through  the  nose-mask.  After  having  placed  my  patient  in  the 
cabinet,  I  open  widely  the  window  of  the  room  in  which  the  cabinet 
stands.  I  do  this  in  office  as  well  as  in  hospital  practice,  be  it 
summer  or  winter,  rain  or  shine,  to  assure  my  patient  the  purest  and 
freshest  air  obtainable.  Since  the  patient  breathes  through  the  nose, 
the  possibility  of  catching  cold  is  removed,  thougii  the  outside  tem- 
perature may  even  be  severely  cold.  In  very  ana;mic  individuals  I 
occasionally  combine  ozone  inhalations  with  the  cabinet  treatment. 

My  second  modification  in  the  pneumatic  treatment  consists  in 
having  the  patient  enter  stripped  to  the  waist,  and  the  trousers  or 
skirts  loosened,  that  not  only  a  free  thoracic  but  also  a  free  abdom- 
inal breathing  may  be  possible.  My  reasons  for  exposing  the 
cutaneous  surface  of  the  thorax  to  dinjct  contact  with  the  rare- 
fied air  are  threefold : 

1.  There  is  no  outside  restriction  whatsoever  to  fullest  expansion 
of  the  lungs — a  thing  which  is  not  possible  for  a  woman  wearing  a 
tightly  laced  corset  and  numerous  skirts  tight  around  the  waist. 
Even  a  man  will  breathe  easier  with  trousers  loosened  and  sus- 
penders removed, 

2.  The  cupping  effect,  if  I  may  call  thus  the  action  of  the 
cabinet    which    relieves    over    one-half    pound    of   atmospheric 


!,:. 


224 


PULMONARY   TUBERCULOSIS. 


i     1 


pressure  per  square  inch,  is  heightened  by  removing  several  inter- 
vening layers  of  clothing. 

3.  It  does  the  cutaneoi  5  surface  good  to  get  a  chance  to  breathe 
directly,  as  it  acts  also  as  a  respiratory  organ  ;  in  other  words,  the 
skin  of  the  Jiest,  made  especially  sensitive  in  nearly  all  con- 
sumptives through  exaggerated  warm  dressing,  will  become  less 
sensitive  by  systematic  exposure  to  the  air. 

To  prevent  the  patient  from  taking  cold  the  window  is  closed 
before  he  is  allowed  to  leave  the  cabinet ;  and  if  he  should  feel  very 
warm,  or  if  he  should  perspire,  as  patients  soiiietimes  do,  a  large 
Turkish  towel  is  thrown  around  his  shoulders,  wherewith  he 
produces  vigorous  friction  over  chest  and  back  before  dressing. 

To  make  the  use  of  the  cabinet  as  comfortable  for  the  patient 
and  at  the  same  time  as  effectual  as  possible,  I  have  added  two 
minor  modifications  in  its  use.  I  had  a  stand  constructed  with  a 
seniicircular  board  top,  which,  placed  in  the  cabinet  in  front  of  the 
chair,  enables  the  patient  to  rest  his  arm  when  holding  the  nose- 
mask.  This  stand  can  be  fixed  at  any  desirable  height.  The 
other  minor  modification  consists  of  a  little  cap  made  of  two  layers 
of  metallic  gauze,  placed  over  the  external  opening  of  the  stop-cock 
communicating  with  the  tube.  Between  the  two  layers  absorbent 
cotton  can  be  placed  in  order  to  filter  the  air  which  enters  the 
tube  when  the  patient  inhales.  The  cotton  can  also  be  impregnated 
with  whatever  medicinal  substance  the  physician  thinks  most 
appropriate.  I  give  the  essence  of  peppermint  the  preference  for 
such  purposes,  for  it  has  a  soothinir^  cooling  influence  on  the  irri- 
tated membranes. 

Like  all  respiratory  exercises,  the  pneumatic-cabinet  treatment 
should  be  begun  carefully  and  gradually.  I  usually  commence 
with  a  seance  of  two  minutes,  increasing  the  duration  from  day  to 
cay  up  to  six  or  eight  minutes.  A.t  first  the  seances  should  be  given 
once  every  day.  As  the  patient's  respiratory  function  becomes 
more  perfect  and  the  disease  tends  toward  recovery,  the  sittings 
need  not  be  quite  as  frequent.  Longer  seances  than  eight  min- 
utes are  seldom  indicated.  About  one  inch  of  elevativjn,  shown 
by  the  manometer,  suffices  to  reduce  the  atmospheric  pressure  a 
little  more  than  half  a  pound  to  the  square  inch.  This  reduction 
is  all  that  is  needed  to  produce  the  desired  effect. 

My  patients,  with  rare  exception,  look  forward  to  their  seance 
with  pleasurable  anticipation,  especially  when  there  is  a  tendency 


THE   PNEUMATIC    CABINET    IN    PULMONARY   TUBERCULOSIS.      225 

to  dyspnoea.  I  have  entered  the  cabinet  myself,  my  assistant 
working  the  lever,  in  order  to  experience  the  sensation  so 
vividly  described  by  some  of  my  patients.  I  cannot  say  that  at 
first  the  feeling  of  being  inclosed  in  such  a  small  space,  with  only 
a  tube  to  breathe  through,  is  a  pleasant  one.  The  first  movements 
of  the  pump  produce  an  almost  painful  sensation  in  the  ears,  but, 
by  and  by,  with  the  exhaustion  of  the  air,  and  by  swallowing  a 
few  times,  this  ceases  and  there  comes  a  feeling  of  freedom.  The 
respiratory  muscles  seem  to  expand  to  a  much  greater  degree;  the 
fresh,  cool  air,  entering  through  the  nose,  arrives  in  the  lungs 
sufficiently  warmed  not  to  be  harmful,  penetrating  habitually 
unused  portions  of  lun'^-substativ-es.  There  comes,  and  remains 
for  hours  afterward,  a  feeling  of  exhilaration  analogous  to  that 
experienced  on  mountain-tops.  On  the  actici  of  the  cabinet  on 
the  various  pathological  conditions  in  pulmonary  tuberculosis,  I 
have  cited  the  experiences  of  Piatt  and  Quimby  ;  as  stated  above, 
I  may  repeat  that  they  coincide  in  nearly  every  respect  with 
mine,  and  I  can  recommend  the  j'ldicious  use  of  this  method  of 
aiirotherapy  most  earnestly.  I  thmk  that  the  few  modifications 
which  I  liave  instituted  in  connection  with  the  employment  of 
the  cabinet  will  tend  to  increase  its  usefulness. 


11 


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Exercise 
during  llie 
application 
of  cold 
walcr. 


CHAPTER  XIV. 

HYUROTHERAPEUTICS  IN  THE  GENERAL  TREATMENT 
OF  PULMONARY  TUBERCULOSIS. 

After  aci'otherapy,  hydrotherapy  conies  next  in  importance  in 
t^'"  treatment  of  pulmonary  tuberculosis.  Of  the  tonic  effects  of 
cold  water,  and  its  stimulation  of  the  general  system,  we  have 
already  spoken  in  the  chapter  on  Preventive  Treatment.  The 
general  education  of  the  cutaneous  and  nervous  systems  of  a 
patient  whose  uody  i^as  not  been  accustomed  to  the  extensive 
application  of  cold  water  is  especially  imperative  in  the  case  of  a 
consumptive.  How  this  should  be  done  has  been  described  in 
detail  on  page  87.  Presuming,  then,  that  the  patient  has  gone 
througl:  the  usual  preparatory  course  of  dry  friction,  friction  with 
alcohol,  with  water,  etc.,  we  come  to  the  douche.  So  as  not  to 
produce  too  great  a  shock,  I  begin  by  directing  a  gentle  stream 
toward  the  feet,  then  rapidly  upward  as  far  as  the  hips ;  then  I 
apply  the  spray  uniformly  all  over  the  body,  and  direct  also  a  small 
jet  with  a  little  more  force  over  the  apices.  Apparatus  for  this 
kind  of  douche  can  easily  be  constructed  in  a  .•5ar<atorium,  or  even 
in  a  private  dwelling. 

There  is  one  thing,  however,  which  I  would  insist  upon  in  the 
arrangement  of  a  douche-room.  A  patient  should  be  taught  to 
exercise  as  many  muscles  as  possible  during  the  application  of 
cold  water.  To  this  end  he  should  take  hold  of  a  bar  fastened 
across  th  ,  room  at  about  the  heiglit  of  his  shoulders.  This  pre- 
vents his  slipping  on  the  wet  floor  while  he  moves  his  thorax  from 
side  to  side,  rai.ses  his  feet  alternately,  moves  his  arms,  and,  'n 
short,  agitates  his  whole  body  as  much  <vs  possible.  The  shock 
produced  by  the  cold  water  is  thus  much  lessened  and  a  more  speedy 
reaction  assured.  Of  course,  the  large  towel  to  envelop  the  jjatient 
from  head  to  foot  is  necessary,  over  which  the  bath-attendant  uses 
vigorous  friction  to  favor  a  proper  reaction  and  return  to  warmth. 
In  some  cases  of  tardy  reaction  warming  the  towels  is  indicated. 

Raruch's  ingenious  douche  apparatus,  of  which  I  give  a  repro- 

226 


HVDROTHERAPEUTICS    IN    PULMONARY   TUBERCULOSIS. 


227 


duction,  could,  with  a  few  additions,  become  an  ideal  installation 
for  a  large  sanatorium  for  consumptives,  ""hese  additions  should  be 
the  cross-bar,  just  mentioned,  in  front  of  the  circular  douche  appa- 
ratus, and  an  arrangement  permitting  direct  jets  to  be  given  from 
above  over  the  apices.  For  this  purpose  two  apertures  could  be 
conveniently  placed  one  on  each  side  of  the  rain  douche  (K).  Here 
is  a  description  of  such  an  installation  as  given  by  Dr.  Baruch 


■ 


I'IG.   72.  — DK.  HaRUCH'S    DoLCHK   All'AKATl'S. 

J'J/.  I'rescriptioii-liolder.  5'.  "SpcoiuI"  clock.  //  Hot  water.  /.  Ice-wattr.  C.  Cold  water. 
/'.  I'rc-ssure  regulator.  J>.  Bell.  G.  GaiiKe.  '/'.  Tlierinoniotcr.  A'.  Rain  doiiclic.  Cr.  Cir- 
cular douche.  Cy.  Cold  jet  douche.  ///.  Hi)l-iet  douche.  //.  Hot  water  for  Scotch  douche. 
C.  Cold  w!>tcr  for  Scotch  <louche.    J/p.  Hi|>-lialh.    67.  Steam  douche. 

hi'.iiself,  in  his  excellent  book  on  the  "  Principles  and  Practice  of 
Hydrotherapy  " '  : 

"A  waiting-room  and  a  number  of  dressina-rooms  havinfr  been  iiarueh's 

°  t>  b  douclie- 

provided,  a  room  containing  two  or  more  cots  for  packs  is  set  aside, '"om  and 

'  °  '  .    apparatus. 

and  another  for  massage.  A  space  twelve  feet  or  more  square  is 
utilized  for  a  douche-room.  This  should  be  constructed  with 
marble  walls  and  be  supplieil  with  ample  light  and  heat.     Above 


^f 


ro- 


'  I'liblisliod  l>v  Win.  Wood  vS;  Co.,  Ni'W  \'oili. 


228 


PULMONARY   TUBERCULOSIS. 


i 


a  water-proof  floor,  which  slants  suflficiently  to  carry  water  into  a 
pipe  leading  to  the  sewer,  a  level,  slatted  floor  should  be  laid  in 
sections,  to  facilitate  remo\  'i^'*  cleansing,  in  such  a  manner  that 
all  the  water  used  upon  the  f  ''^  may  readily  flow  through  the 
interstices  between  the  slats  u^  .  the  water-proof  floor  beneath. 
Upon  the  upper  extremity  of  this  floor  a  circular  douche  may  be 
secured.  Adjoining  this  a  large  bath-tub  and  sitzbath-tub  may  be 
placed,  the  latter  having  sufficient  space  to  admit  an  attendant 
behind  it.  The  douche-table  should  be  so  constructed  that  its 
supply  of  hot,  cold,  and  ice  water  is  sufficient  for  all  requirements. 

"  The  douche-table  is  a  box  four  feet  long,  three  feet  high,  and 
two  feet  wide,  covered  with  marble.  Inclosed  within  the  box  is  a 
combination  of  pipes  connected  with  the  hot  and  cold  water-supplies 
and  steam-supply  on  the  one  hand,  and  with  the  hose  and  other  ter- 
minal arrangements  on  the  other.  The  hot  and  cold  water-supplies 
are  controlled  by  stop-cocks  by  the  usual  contrivance,  the  terminal 
rods  and  levers  of  which  issue  through  openings  in  the  upper  flat 
portion  or  slab  of  the  douche-table,  as  may  be  seen  in  the  dia- 
gram. The  attendant,  standing  behind  the  table,  is  protected 
against  receiving  the  water  recoiling  from  the  patient,  and  is  per- 
fectly free  to  regulate  the  outflow  according  to  the  prescription 
ordered  in  each  case.  An  outflow  pipe,  controlled  by  the  stop- 
cocks, Pa.nd  R,  regulates  the  pressure  of  the  water,  which  is  plainly 
indicated  upon  the  gauge.  This  enables  the  attendant  to  arrange 
any  pressure  required,  either  before  the  douche  is  administered  or 
while  it  is  flowing  upon  the  body,  the  range  being  from  ten  to 
thirty-five  pounds.  A  thermometer,  T,  is  so  arranged  that  its  bulb, 
encased  in  an  open-work  metal  tube,  lies  within  the  mixer,  whose 
outlet  pip*  leads  to  the  hose;  and  its  upper  portion,  cased  in  metal 
also,  shows  through  a  magnifying  glass-tube  cover  the  temperature 
of  the  water  flowing  upon  the  patient.  A  '  second  '  clock,  C, 
furnishes  information  regarding  duration,  while  the  clasp,  CI,  holds 
the  prescription  out  of  reach  of  the  spray.  The  apparatus  is  put 
into  operation  as  follows  : 

"  The  attendant  places  the  prescription  in  the  clasp  after  care- 
fully scanning  it,  and  opens  the  stop-cocks  which  close  the  nozzle. 
He  now  opens  the  hot-  and  cold-water  faucets,  and,  watching  the 
thermometer,  obtains  the  temperature  required  while  the  water  is 
flowing.  This  may  be  done  with  the  greatest  ease  after  some 
practice.     He  now  opens  tlie  pressure  regulator  until  the  gauge 


mm 


HYDROTHERAPEUTICS    IN    PULMONARY   TUBERCCtOSIS.  229 


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PULMONARY   TUBERCULOSIS. 


registers  the  pressure  prescribed.  The  attendant  having  examined 
the  thermometer  again,  and  holding  the  faucet-handle  in  the  left 
hand,  while  the  right  holds  to  one  side  the  hose  from  which  the 
stream  of  water  is  issuing,  requests  the  patient  to  place  himself  six 
feet  in  front  of  the  douche-table.  Again  looking  at  the  thermom- 
eter to  insure  the  exact  temperature  prescribed,  he  now  directs  the 
stream  upon  the  patient's  back  ;  other  parts  are  treated  successively 
as  ordered  by  the  physician.  If  a  circular  douche  is  ordered,  the 
water  is  also  turned  on  before  the  patient  enters  it.  This  is  impor- 
tant, not  only  because  shock  is  thus  prevented,  but  timidity  of  the 
patient  is  overcome. 

"  The  circular  douche  used  here  differs,  as  the  diagram  shows, 
from  the  usual  needle-bath,  in  not  being  supplied  with  semicircular, 
perforated  pipes.  I  found  the  effect  greatly  enhanced  and  much 
trouble  from  stoppage  avoided  by  the  substitution  of  eight  roses, 
three  inches  in  diameter.  Each  rose  contains  fifty  fine  openings 
in  the  plate,  which,  being  screwed  on  to  the  connecting-tube,  may 
thus  be  easily  freed  from  accumulating  sand  and  dirt.  Moreover, 
the  three  upper  roses  are,  by  a  device  of  Mr.  Frank  Richter,  made 
movable.  By  simply  turning  these  roses  downward,  an  adult  of 
any  height  may  be  treated  without  having  the  face  sprinkled  or 
the  ears  filled  with  water. 

"  The  douche-table  contains  pipes  the  outlets  of  which  are  con- 
trolled by  lever  faucets,  which  also  open  and  close  the  perinaeal 
douche,  the  hip-bath,  and  the  full  bath.  The  temperature  of  these 
may  thus  be  controlled  by  the  attendant  by  simply  watching  the 
thermometer  of  the  douche-table. 

"There  should  also  be  a  steam  douche,  supplied  with  low-pres- 
sure steam  from  tlic;  engine-room,  which  may  be  made  to  issue  from 
the  hose  by  opening  the  faucet  St. 

"  The  douche-room  is  twelve  feet  long  and  eight  feet  wide,  its 
walls  being  covered  with  marble  eight  feet  high.  The  floor  of  this 
compartment  is  slanting  and  covered  with  copper  ;  the  edges  of  the 
latter  are  secured  by  being  turned  up  two  inches  behind  the  lower 
edge  of  the  marble  wall.  Beams  cut  slanting  on  the  lower  side 
to  fit  the  water-tight  floor,  and  straigiit  on  the  upper  side,  are  laid 
horizontally,  so  as  to  support  a  slatted  floor,  through  which  all  the 
water  flows  upon  the  copper  beneath  and  thence  to  the  sewer. 

"The  water-supply  comes  from  a  reservoir  (under  the  roof),  to 
which  it  is  pumped  by  a  stean   engine.     The  hot  water  is  furnished 


I 


HYDROTHERAPEUTICS   IN    PULMONARY   TUBERCULOSIS. 


>3I 


from  a  drum  which  is  heated  by  steam  coils.  Both  cold  and  hot 
water  flow  through  appropriate  pipes  to  the  douche-table,  and  ice- 
water,  which  is  required  in  summer,  is  furnished  by  a  cooling 
apparatus  construct'.-d  as  follows :  In  the  basement  is  situated  a 
box,  seven  by  five  feet  and  four  feet  high,  which  has  double  walls 
four  inches  apart.  A  manhole,  2^^  feet  square  on  top,  admits  of 
ice  being  thrown  in.  The  box  is  lined  with  copper,  so  as  to  be 
water-tight.  At  the  bottom  two  boards,  two  inches  thick  and  one 
foot  deep,  are  placed  from  one  side  to  the  other.  These  have 
three  semicircular  notches,  fitting  three  galvanized-iron  cylinders, 
for  which  they  form  a  support. 

"  The  cylinders  contain  thirty  gallons  each  and  are  connected 
with  each  other  by  inch  pipes.  The  first  cylinder  receives  the 
water-supply  from  a  two-inch  main.  The  water  entering  this  cyl- 
inder passes  to  the  second,  thence  at  the  opposite  end  to  the  third, 
from  which  it  issues  into  an  inch  pipe  leading  to  the  douche-table 
in  the  room  above. 

"  Six  inches  above  the  level  of  the  cylinders  an  inch  opening 
exists,  which  is  connected  with  the  sewer.  A  separate  pipe,  sup- 
plied with  a  stop-cock,  should  also  lead  from  the  main  directly  into 
the  box,  for  the  purpose  of  filling  the  latter  with  water  as  high  as 
the  outlet  above  the  level  of  the  cylinders. 

"  The  box  is  elevated  about  one  foot  from  the  floor,  and  an  out- 
flow pipe  with  stop-cock  should  be  securely  connected  with  the 
latter  and  lead  to  the  sewer,  for  the  purpose  of  emptying  the  box 
when  necessary.  The  apparatus  is  prepared  as  follows:  The  stop- 
cock of  the  pipe  A,  leading  from  the  main,  is  opened  for  the  pur- 
pose of  filling  the  cylinders;  the  stop-cock  C at  the  bottom  of  the 
box  being  closed,  the  stop-cock  B  is  opened  and  water  is  allowed 
to  flow  into  the  copper-lined  box  until  the  cylinders  are  covered 
with  water  six  inches  deep.  Now  half  a  ton  of  ice  is  put  upon 
the  cylinders.  It  will  be  observed  that  the  lower  portion  of  the 
ice-supply  lies  in  six  inches  of  water,  which  covers  the  cylin- 
ders. Thus  the  latter  are  not  only  covered  by  ice,  but  surrounded 
by  ice-water.  As  the  ice  melts,  the  overflow  of  water  issues  through 
the  opening  A' to  the  stop-cock  I),  which  is  always  left  open. 

"  The  necessity  for  this  ice-water  supply  will  be  evident  when 
it  is  borne  in  mind  that  in  midsummer,  when  the  temperature  of 
the  water   may  range    from  70°   to  80°    F.,  a  prescription    for  a 


1  ,:. 


n 


232 


PULMONAKY   TUBERCULOSIS. 


I 


Improvised 
douche- 
arrange- 
ment. 


Time,  tem- 
perature 
and  dura- 
tion o( 
douclie. 


douche  of  50°  to  60°  F.  could  not  be  filled  without  such  a 
supply.  It  is  necessary  only  to  open  the  ordinary  cold-water  sup- 
ply-cock, as  is  needed,  to  reduce  the  former  to  the  temperature 
prescribed." 

In  cases  where  the  visit  to  the  douche-rcom  is  either  incon- 
venient or  not  safe,  I  resort  to  the  following  simple  method :  A 
wooden  chair  is  placed  in  a  large,  circular,  English  bath-tub,  and 
the  patient  sits  astride  the  chair,  holding  the  back  with  his  hands 
and  bending  his  head  slightly  forward.  Then  two,  four,  or  more 
pitchers  of  cold  or  tempered  water  are  rapidly  poured  over  the 
shoulders.  In  cases  where  the  reaction  is  feeble  the  patient  is 
quickly  put  back  into  his  warm  bed,  even  if  not  thoroughly  dry. 

The  best  time  to  take  the  hydrotherapeutic  application  is  in  the 
morning,  half  an  hour  or  so  after  a  very  light  breakfast.  Patients 
accustomed  to  heavy  breakfasts  should  take  such  after  their  douche 
and  morning  walk,  but  should  take  a  glass  of  milk  with  a  slice  of 
buttered  toast  before  leaving  their  room.  A  morning  walk  should, 
if  possible,  always  precede  the  douche.  This  is  for  the  purpose  of 
creating  what  French  hydrotherapeutists  call  a  preaction. 

Every  douche  or  affusion  should  also  be  followed  by  a  short 
walk  or  a  return  to  bed,  according  to  the  indication  of  the  case. 
The  cold  douche  should  never  last  longer  than  twenty  to  twenty- 
five  seconds,  and  one  should  always  begin  gradually,  not  giving 
more  than  five  seconds  at  first.  The  temperature  may  vary  from 
60°  to  40°  F.  Only  in  exceptional  cases  would  one  need  a  more 
precise'graduation  of  the  temperature. 

The  complicated  procedure  of  the  dripping  sheet  seems  to 
entail  too  great  a  strain  on  the  patient,  and  I  do  not  favor  it  in 
phthisio-therapeutics.  Wet-packs,  on  the  contrary,  over  the 
thorax,  seem  to  exert  a  soothing  influence  whenever  there  are 
pleuritic  or  intercostal  pains,  or  that  vague  and  undetermined 
feeling  of  discomfort  in  the  chest.  Lateral  douches,  not  too 
strong,  directed  toward  the  seat  of  old  pleuritic  adhesions,  often 
aid  considerably  in  the  resorption  of  the  fibrinous  bands  and  a 
consequent  free  chest-expansion. 

In  patients  above  fifty,  it  must  be  remembered  that  the  usual 
reaction  after  a  cold  douche  is  slow  to  come,  and  in  such  cases  it 
is  best  not  to  use  the  water  too  cold.  A  chilly  sensation,  con- 
tinuing  even  after   thorough  drying  and  friction,  should    in    all 


HYDROTHERAPEUTICS    IN    PULMONARY   TUBERCULOSIS. 


233 


cases  be  a  warning  and  a  guide  regarding  temperature  and  duration 
of  the  douche.  There  are  idiosyncrasies  which  must  also  be  con- 
sidered with  some  patients  in  regard  to  the  application  of  a  cold 
douche. 

Of  the  other  uses  of  cold  water  in  pulmonary  tuberculosis  we 
will  speak  under  symptomatic  treatment. 


m 


IIP 
§ 


\T-!t 


e.l 


•M  ! 


/--rsssetftts- 


CHAP'IKR   XV. 


PERSONAL  HYGIENE  AND  DRESS  OF  THE  TUBERCULOUS 

PATIENT. 

The  care  of  the  skin  is  an  essential  part  in  phthisio-therapy.  As 
a  rule,  a  tuberculous  patient  should  take  his  hygienic  baths  regu- 
larly once  or  twice  a  week.  It  should  be  of  short  duration,  not 
too  warm,  and  followed  by  a  rapid  sponging  off  with  cold  water. 
The  best  time  to  take  the  hygienic  bath  is  in  the  evening,  before 
retiring.  A  pulmonary  invalid  should  never  take  his  bath  without 
there  being  some  one  within  call,  in  case  he  requires  any  assistance. 
When  the  skin  is  especially  dry,  nothing  will  be  better  than  an 
occasional  massage  with  vaseline  or  some  other  oily,  not  irritating 
substance. 

Whether  a  consumptive  uses  a  pocket-flask,  squares  of  muslin, 
or  a  paper  spittoon  for  the  purpose  of  expectorating  therein,  it  is 
well  to  repeat  here  that  he  should  be  enjoined  to  wash  his  hands 
always  most  thoroughly  before  touching  food.  Of  the  harmful 
effects  of  swallowing  the  expectoration,  we  have  already  spoken 
when  treating  of  infection  by  ingestion  (chap.  iv). 
General  Consumptives  should  dress  sensibly,  comfortably,  and  according 

ceniltig"  to  the  season.  They  should  avoid  heaping  successive  layers  of 
both  sexes,  clothing  upon  themselves,  especially  in  the  line  of  so-called  chest- 
protectors.  These  latter,  or  the  numerous  woolen  undershirts, 
often  worn  by  the  pulmonary  invalid,  have  been  :ii  many  cases  the 
very  cause  of  contracting  repeated  colds  by  having  rendered  the 
individual  too  sensitive.  Consumptives  should  have  warm  outer 
garments  for  winter,  but  not  so  heavy  as  to  hamper  their  move- 
ments. For  under-garments,  Jiiger's  or  similar  sanitary  wocl  suits, 
the  lighter  or  heavier  grade,  according  to  the  season  or  the  climate, 
are  to  be  recommended.  The  shrinking  of  these  garments  can  be 
prevented  by  well-prepared  soapsuds  and  the  use  of  proper 
stretchers  during  drying.  To  overcome  the  unpleasant  pressure 
caused  by  the  suspenders,  to  which  the  consumptive  is  more  sensi- 
tive than  others,  this  article  of  dress  might  be  replaced  by  a  sort 

234 


PERSONAL    IIYGIENK   AND    DHKSS. 


235 


: 


of  vest,  of  light,  elastic  material,  to  which  the  trousers  are  attached, 
thus  distributing  the  pressure  over  a  larger  surface.  Instead  of 
four  or  six  there  are  eight  to  ten  attachments  (see  illustration). 
Whenever  and  wherever  conventionalism  does  not  reign  supreme, 
the  starched  linen  should  be  replaced  by  the  light,  woolen,  negligee 
shirt.  It  permits  better  ventilation  and  freer  respiratory  move- 
ments. Men  with  a  good  head  of  hair  need  not  fear  to  go  Hcadwear 
uncovered  at  tirnes,  but  all,  even  those  with  thin  hair  or  bald'"'^""" 
heads,  should  not  wear  too  heavy  hats  or  caps,  and  should  always 
have  them  well  ventilated. 

In  the  chapter  on  Infection  by  Ingestion,  we  stated  already  that 
to  wear  no  beard  and  no  mustache  would  be  the  most  hygienic 
practice  on  the  part  of  the  consumptive;  but  since  it  is  very  hard 
to  enforce  rules,  the  carrying  out  of  which  would  change  the 
appearance  of  a  person  often  to  a  con- 
siderable degree,  it  is  best  to  simply 
advise  the  tuberculous  invalid  to  keep 
his  beard  and  mustache  as  short  as 
possible,  and  to  wash  the  same  with 
warm  water  regularly  a  few  times  dur- 
ing the  day. 

As  a  matter  of  personal  hygiene  for 
pulmonary  invalids,  I  should  again 
suggest  not  to  make  use  of  tobacco 
in  any  form  whatever. 

For  the  women  I  would  recommend 
the   Lady  Habberton  or  Jenness   Miller  system  of  dress  reform. Je",""s 

^  ■'  -^  _  Miller 

It  may  not  be  amiss  to  give  a  short  description  of  the  system -Ys'_,*='"°f 
here,  for,  while  it  may  enjoy  a  certain  popularity  among   sani-^°"'"'- 
tarians,  I  cannot  say  that  the  majority  of  ladies  seem  to  be  very 
familiar  with  this  reform.    "  Dame  Fashion  "  has,  no  doubt,  a  great 
deal  to  do  with  the  seemingly  total  ignorance  of  this  most  healthful 
mode  of  dress  among  otherwise  well-informed  ladies. 

According  to  the  fundamental  rules  for  dress  reform  as  advocated 
by  Lady  Habberton,  Mrs.  Miller,  and  others,  the  garments  are 
arrangeil  so  that  they  follow  the  symmetrical  lines  of  the  female 
form,  and  in  all  possible  cases  are  made  of  one  piece.  Each  limb  is 
properly  clothed  in  its  turn.  Legs,  arms,  and  neck  are  comfortably 
and  closely  protected,  while  the  body  is  wrapped  a  little  tighter. 
The  under-garment  is  made  all  in  one  piece,  and  with  no  bands 


KiG.    74.— XliST-SLSPENDHRS. 


^1 


'■ 


IT* 

li],) 
,  V  ' 
I  'I'l' 

r 


'1;: 


Footwear. 


236 


PULMONARY   TUBERCULOSIS. 


around  the  waist.  If  a  corset  must  be  worn  it  should  be  corded 
or  stifiened  with  a  few  whalebones  and  never  tightly  laced,  which, 
with  the  weij^ht  of  the  heavy  .skirts  fastened  tightly  around  the 
waist  in  the  usual  manner,  renders  all  abdominal  breathing  im- 
possible. As  has  been  already  stated  in  our  chapter  on  prophy- 
lactic treatment,  abdominal  breathing  is  as  natural  to  women  as  it 
is  to  men  and  animals. 

Next  to  this  under-garment,  or  union  suit,  a  so-called  "  chenii- 
lette  "  is  worn,  made  on  the  same  principle  as  the  ,  nder-garment, 
but  of  looser  and  lighter  material.  The  third  in  order  is  the  so- 
called  "  leglette,"  a  divided  skirt  and  waist  attached,  which  gives 
the  wearer  great  comfort  and  freedom  of  motion.  It  can  be  made 
of  almost  any  material.  And  now  as  to  the  outside  dresses  :  They 
are  made  as  nearly  as  possible  in  the  styles  in  vogue,  but  never 
with  trains,  and  in  them  all  are  preserved  the  physiological  feat- 
ures of  the  female  form.  In  the  complete  toilet  all  garments  are 
so  arranged  that  their  whole  weight  is  supported  by  the  shoulders, 
and  no  pressure  whatever  brought  to  bear  upon  any  of  the  vital 
organs  in  either  thoracic  or  abdominal  cavity. 

I  have  frequently  seen  ladies  dressed  according  to  this  sensible 
mode,  and  I  can  assure  the  doubting  reader  that  they  looked  to 
me  and  to  others  more  becomingly  dressed  and  more  graceful 
than  those  arrayed  in  the  very  latest  fashion,  whose  waists  have 
been  reduced  by  tight-lacing,  changing  their  appearance,  perhaps, 
from  the  figure  of  a  Venus  to  something  resembling  two  cones 
placed  with  their  summits  in  apposition. 

Phthisical  patients  should  keep  their  feet  warm  and  dry,  and 
should  never  wear  tight  shoes.  Rubber  shoes  when  it  is  wet,  fur- 
lined  ones  when  it  is  cold,  and  hot-water  bags  or  bottles  at  their 
feet  when  lying  on  their  chairs  in  winter,  should  be  recommended 
to  attain  this  end. 


i  ; 


I   !i 


I    il 


("IIAPTKR  XVI. 
DIHTHTIC  TREATMHNT  OF    PULMONARY  TUBERCULOSIS. 


To  nourish  the  patient,  to  feed  liini  well  with  ,-;oo(J  food,  or 
rather  overfeed  him  so  that  he  assimilates  more  than  he  expends, 
forms  an  important  part  of  the  treatment  of  phtl'lsis.  The  patient 
should  have  an  abundance  of  proteids,  carbohydrates,  and  fats, 
but  in  proper  proportion  ;  thus  the  menu  for  a  tuberculous  invalid 
should  be  much  varied.  He  should  never  have  a  diet  exclu- 
sively of  meat,  nor  of  vegetables ;  a  mixed  diet,  with  some  eclecti- 
cism as  to  the  more  digestible  substances,  should  be  the  rule. 
Meat,  milk,  fats,  eggs,  vegetables,  bread  (cereals),  fruits,  especially 
grapes,  should  all  contribute  to  the  diet  of  the  patient. 

Consumptives,  as  a  rule,  have  small  appetites,  and  it  requires 
sometimes  no  little  art  to  make  them  eat.  The  one  important 
truth  that  they  should  be  made  to  understand  is  that  their  digestive 
powers  are  far  greater  than  their  appetite  indicates.  Leaving  ex- 
ceptional cases  aside,  such  as  absolute  anorexia,  hyperacidity,  or 
lack  of  gastric  secretion,  of  which  we  will  speak  later,  one  usually 
succeeds  in  making  the  patients  eat  by  persistent  persuasion,  and 
by  offering  them  a  variety  of  food  arranged  as  appetizingly  as  pos- 
sible. 

The  meaij  given  the  patients  in  the  leading  European  sanatoria 
are  about  as  follows :  In  the  morning — half-past  seven  to  half-past 
eight  o'clock — they  have  bread  and  butter  and  honey,  with  cocoa, 
coffee,  or  chocolate,  and  two  or  three  glasses  of  milk  taken  slowly 
in  small  swallows.  At  ten  o'clock  they  have  bread  and  butter, 
cold  meats,  fruit,  etc.  At  one  o'clock  the  dinner — soup,  fish,  three 
kinds  of  meat,  vegetables,  salad,  preserves,  dessert,  and  fresh  fruit, 
with  one  or  two  glasses  of  wine.  At  four  o'clock  they  have  a  glass 
of  milk,  with  bread  and  butter.  At  half-past  seven  there  are  thick 
soup,  meat  and  potatoes  or  rice,  cold  meat,  bread  and  butter,  salad, 
and  cooked  fruit,  with  again  one  or  two  glasses  of  wine.  At  nine 
o'clock  they  take  a  glass  of  milk  with  two  or  three  teaspoonfuls  of 
cogijac. 

■^17 


'}■: 


■  I : 


it-- 


1'  ^  ■■,•)!•  i 


eS  >k! 


4m 
n 

i 


238 


PULMONARY   TUBERCULOSIS. 


if 


Average 
regime. 


To  eat  a  great  deal  of  butter  and  cream  is  especially  to  be 
recommended  to  pulmonary  invalids,  and  milk  should  be  allowed 
at  any  time  without  restriction.  However,  some  patients,  in  their 
eagerness  to  get  fat,  overdo  in  this  respect.  When  crinking 
numerous  glasses  of  milk  between  meals  interferes  with  the  proper 
appetite  at  meal-times,  the  number  of  glasses  should  be  reduced 
accordingly.  Again,  neither  milk  nor  cream  agree  well  with  some 
consumptives.  To  make  the  latter  more  digestible,  one  may  add 
to  each  wineglassful  one-half  or  one  teaspoonful  of  cognac,  kirsch, 
or  rum,  with  or  without  hot  water.  Milk  may  be  tendered  more 
digestible  by  adding  to  each  tumblerful  about  six  grains  of  bicar- 
bonate of  soda  and  five  grains  of  common  salt,  dissolved  in  two 
tablespoonfuls  of  hot  water. 

The  pulmonary  invalid  must  be  treated  and  fed  in  accordance 
with  what  he  was  accustomed  to  before  being  taken  sick,  for  meal- 
times and  number  of  meals  differ  among  most  nationalities. 

For  average  cases  I  would  suggest  the  following  regimen,  to  be 
adhered  to  as  nearly  as  possible  during  the  cour.se  of  the  disease  : 
As  soon  as  the  patient  awakes  in  the  morning,  while  yet  in  bed,  a 
glass  of  hot  milk,  half  milk  and  tea,  or  half  coffee  and  milk,  with 
a  slice  of  milk-toast,  should  be  given  him.  After  a  little  while  he 
will  rise  to  prepare  for  his  douche,  friction,  or  massage,  whatever 
the  physician's  prescription  may  call  for.  After  this  it  will  probably 
be  nine  o'clock,  and  the  patient  may  take  his  ordinary  breakfast. 
He  should  have  egg",  :nd  may  have  his  choice  as  to  the  way  they 
may  be  prepared  or  .served — soft-boiled,  poached,  raw,  etc.,  or  in 
form  of  egg-nog,  with  sherry  or  whiskey.  If  he  is  accustomed  to  a 
meat  breakfast,  he  should  have  broiled  steak,  chops,  poultry,  sweet- 
bread, etc.,  or  raw  chopped  beef.  Bread  a  day  old, — preferably 
whole-wheat  bread  or  French  rolls,  but  not  hot, — with  plenty  of 
butter  or  honey,  either  milk,  cocoa,  coffee  with  milk,  but  not  too 
strong,  or  a  cup  of  bouillon,  should  also  form  part  )f  the  meal. 
Whether  the  patient  likes  to  have  his  mush  (cereals)  for  breakfast 
or  supper,  may  be  left  to  his  choice  ;  some  fruit  should  always 
precede  his  eggs  or  meat  in  the  morning.  If  fish  is  served  in  the 
morning  it  should  be  either  broiled,  boiled,  or  baked. 

The  patient  should  take  the  heartiest  meal  between  the  hours  of 
twelve  and  two  o'clock  (four  hours  after  his  breakfast).  liroths  or 
soups  should  be  the  first  course.  Oysters  and  clams  are  most 
easily  digested  raw.    Any  kind  of  fresh  fish  may  be  served  again  at 


I     I  i 


DIETETIC   TREATMENT   OF   PULMONARY   TUBERCULOSIS. 


!39 


of 
or 

ost 
at 


dinner,  and  in  any  form  except  fried ;  and  there  will  be,  of  course, 
roast  meat  of  some  kind,  rare  roast  beef,  mutton,  poultry,  etc.  Of 
vegetables,  spinach  is  particularly  to  be  recommended  on  account 
of  the  large  proportion  of  digestible  and  assimilable  iron.  Next 
to  this  in  nutritive  power  come  lentils,  peas,  beans,  cauliflower, 
potatoes.  Fresh  vegetables  should  be  given  whenever  it  is  possi- 
ble to  have  them.  Lettuce  and  other  salads,  preferably  prepared 
with  lemon-juice  instead  of  with  vinegar,  are  permitted.  Light 
puddings,  fruits,  and  nuts  may  constitute  the  dessert. 

At  about  four  or  five  o'clock  some  milk  with  toast  may  be  taken, 
or,  if  the  patient  cares  for  it,  he  should  have  a  cheese  or  meat  sand- 
wich. At  this  time  the  milk  may  be  replaced  by  bouillon  or 
chocolate. 

The  supper  should  not  be  quite  as  voluminous  as  the  dinner. 
Cold  or  warm  meats,  rice  with  milk  or  gruel,  with  jellies,  fruits,  etc. 
At  bed-time  again  a  glass  of  milk  or  some  milk-toast. 

It  is,  of  course,  impossible  to  lay  down  an  absolute  rule  of  what 
to  allow  and  what  not  to  allow.  One  must  consider  the  patient's 
likes  and  dislikes;  there  are  idiosyncrasies  for  certain  dishes  as 
well  as  for  certain  medicines.  I  have  learned  to  allow  my  patients 
occasionally  such  things  as  ham,  smoked  tongue,  and  even  pickled 
or  salt  herring,  sardines,  and  sardelles,  and  I  have  not  yet  found  any 
occasion  to  regret  this  practice,  for  they  seem  at  times  to  stimulate 
the  appetite. 

The  kitchen  should  be  the  phthisio-therapeutist's  pharmacy.  In 
a  sanatorium  the  menu  should  be  submitted  to  the  medical  director 
previous  to  its  preparation.  I  will  give  a  few  receipts  for  particu- 
larly useful  dishes  which  I  have  seen  served,  or  eaten  myself,  dur- 
ing my  voycTigL'  d' etude  in  sanatoria,  and  have  since  tried  with  my 
private  patients  with  most  satisfactory  results.  First,  I  desire  to 
describe  an  excellent  method  of  preparing  the  raw  beef,  or  the  so- 
called  raw  Hamburg  steak,  for  which  receipt  I  am  indebted  to  my 
distinguished  teacher.  Professor  Grancher,  of  Paris : 

With  a  knife,  not  too  sharp,  scrape  the  surface  of  the  meatprciM 
(rump-steak).  Put  the  fine  scrapings  thus  obtained  in  a  stone  or  beef.'' 
glass  mortar  and  grind  them.  Then  spread  the  mass  on  a  sieve 
and  press  it  gently  with  a  spoon.  What  passes  through  is  a  meat- 
pulp  without  fibres  or  gristle,  perfectly  digestible  and  very  nutri- 
tive. (I  have  found,  however,  that  for  all  ordinary  cases  the 
scraped  meat  suffices  without  being  ground.) 


'-  W 

m 


riiiK 
law 

-■'^m 

"If 

h 


ll 


MucilaRii: 
oils  soup. 


Beef 
essence. 


240 


PULMONARY   TUBERCULOSIS. 


The  supply  of  meat-pulp  for  the  day  may  be  made  in  the  morn- 
ing, but  it  must  be  kept  in  a  cold  place,  as  it  taints  easily.  It  is 
better,  when  possible,  however,  to  make  it  fresh  just  before  it  is  to 
be  eaten.  The  patient  may  take  the  pulp  in  any  way  he  pleases. 
It  can  be  eaten  plain  with  pepper  and  salt,  mixed  with  milk,  with 
warm  bouillon,  with  mashed  vegetables,  or  with  sweets.  The  latter 
method  will  make  it  tempting  for  children.  It  can  be  rolled  into 
balls  easy  to  swallow,  or  made  into  sandwiches  with  a  few  anchovies 
or  a  little  anchovy-paste,  pickled  herring,  or  some  other  relish, 
according  to  the  patient's  taste.  The  yolk  of  a  raw  egg  added 
increases  the  nutritive  quality  of  the  meat-pulp.  Thus  it  will  be 
seen  that  the  ways  in  which  the  raw  meat  may  be  taken  are  so 
numerous  that  it  can  be  made  palatable  to  almost  any  patient. 

To  make  a  good  mucilaginous  soup,  take  five  pounds  of  veal- 
bones  and  ten  quarts  of  water  or  weak  bouillon.  Bring  it  to  a  boil 
and  then  skim.  Add  two  pounds  of  barley  and  a  little  salt,  cook 
slowly  for  five  or  six  hours,  and  then  strain  off  the  liquid.  A  cup- 
ful should  be  taken  mixed  with  the  yolk  of  an  egg.  If  the  soup 
is  too  thick,  dilute  it  with  a  little  bouillon. 

To  prepare  a  good  milk-jelly,  boil  two  quarts  of  milk  with  a 
half  pound  of  sugar  for  five  or  ten  minutes.  When  the  milk  is 
cold  add  one  ounce  of  gelatine  dissolved  in  a  cup  of  water,  the  juice 
of  three  or  four  lemons,  and  three  glasses  of  good  Bordeaux  wine. 

It  is  often  very  convenient  to  have  a  bottle  of  beef-essence  on 
hand.  The  following  is  an  easy  method  to  prepare  it :  Put  two 
pounds  of  round-steak,  cut  in  small  pieces,  into  ajar  without  water. 
Place  the  jar,  covered  closely,  on  a  trivet  in  a  kettle  of  cold  water. 
Heat  gradually,  and  keep  it  not  quite  at  the  boiling-point  for  two 
hours,  or  till  the  meat  is  white.  Strain,  pressing  the  meat  to 
obtain  all  the  juice  ;  season  with  salt.  Or  place  the  jar  in  a  mod- 
erate oven  for  three  hours.  The  liquid  thus  obtained  contains  all 
the  nutritive  parts  of  the  meat.  It  may  be  kept  in  the  refrigerator, 
and  a  small  portion  heated  (not  boiled)  as  wanted.  Or  it  may  be 
made  into  beef-tea  by  diluting  with  boiling  water.  The  essence 
can  also  be  given  ice  cold  to  febrile  patients. 

All  bouillons  and  soups  taken  regularly  at  the  principal  meal 
stimulate  the  appetite  and  aid  the  digestion  by  stimulating  the 
gastric  secretions. 

A  patient  who  has  fever  should  eat  when  his  temperature  is 
lowest,  and  only  the  most  easily  digested  substances.     All  pul- 


DIETETIC   TREATMENT    OF    PULMONARY   TUBERCULOSIS.  24 1 

monary  invalids  should  be  taught  to  take  their  meals  at  regular 
intervals,  eat  slowly,  and  chew  their  food  well.  Everything  should 
be  resorted  to  to  make  the  patients  eat,  for  in  this  lies  the  secret 
of  the  success  of  the  treatment.  The  patient  should  be  weighed 
and  carefully  examined  every  month  or  two  weeks,  according  to 
his  condition,  and  thus  the  progress  of  the  cure  can  be  controlled. 
The  good  condition  of  the  teeth  i:;,  of  course,  essential,  and  a  well-Carcof 
conducted  sanatorium  should  not  be  without  its  dental  chair,  and 
should  receive  the  regular  visits  of  an  experienced  dentist. 

The  physician  should  teach  his  consumptives  that  it  will  in- 
crease their  appetites  to  brush  their  teeth  and  rinse  their  mouths 
after  each  meal.  This  is  seemingly  a  trifle,  but  I  have  found  that 
it  has  helped  me  much  in  my  dealings  with  the  bad  eaters  among 
my  patients.  Of  all  preparations  I  give  the  following  tioth-wash 
the  preference  : 

K .     Essence  of  peppermint, .  Vl\^x 

Oil  of  wintergieen, rt\_  xv 

Thymol yr.  xv 

Benzoic  .acid, 3  'U 

Tr.  of  eucalyptus, s  ij 

Alcohol, ^5  XV. 

M.    SlG. — One-half  teaspoonful  to  be  diluted  in  a  tumblerful  of  water. 

This  leaves  a  pleasant  freshness  in  the  mouth. 

Opinions  in  regard  to  giving  alcohol  to  consumptives  differ  very  aicoI.oi 
largely,  and  it  is  extremely  difficult  to  lay  down  any  rule  on  this 
subject.  My  own  experience  has  taught  me  that  it  is  indispen- 
sable in  some  cases,  but  it  should  be  given  preferably  in  the  diluted 
form  of  wine  or  beer,  or  good  cognac  in  small  quantities  mixed 
with  milk.  It  should  rarely  be  given  as  an  antipyretic  remedy. 
When  prescribed  in  the  form  of  cognac  or  whiskey,  it  should  be 
dealt  out  carefully  like  powerful  and  dangerous  medicine. 

This  is  another  advantage  of  treating  the  patients  in  a  sanato- 
rium where  they  are  seen  several  times  a  day.  The  effect  of  the  alco-  ■ 
hoi  or  any  other  medicine  can  be  watched.  The  physician  of  a  sana- 
torium, seeing  his  patient  almost  constantly,  will  soon  be  able  to 
judge  whether  the  improvement  the  patient  may  confess  to  feel  after 
taking  the  alcohol  is  physiological  or  pathological  (intoxication). 

Of  the  many  food-substances  which   have   been   recommended  Tropon. 
recently  as  especially  valuable   in  the  dietetic  treatment  of  tuber- 
culosis, I  have  used  most  extensively  and  with  most  satisfactory 
results  the  new  product,  tropon. 
16 


i: 


I  I 


,ftH( 


I    M 


^ 


24: 


PULMONARY   TUBERCULOSIS. 


\¥i  '.■-- 


Ill 


At  the  Ninth  International  Congress  for  Hygiene  and  Demog- 
raphy, held  in  Madrid  in  April,  1898,  Professor  Finkler,  of  Bonn, 
made  his  first  communication  ontropon,  under  the  title  of  albumen 
nutriment.' 

Tropon  is  a  tasteless  and  odorless,  albuminous  preparation  in 
the  form  of  a  yellowish-brown  powder,  obtained  through  a  com- 
plicated chemical  process  from  animal  and  vegetable  substances. 
Among  animals,  fish,  and  among  vegetables,  the  lupines,  which  or- 
dinarily are  not  suitable  for  the  preparation  of  food  for  men,  have 
been  largely  used.  Tropon  is  supposed  to  represent  over  ninety 
per  cent,  of  pure  albumen.  The  clinical  experiments  made  by  Pro- 
fessor Finkler  and  his  pupils  with  this  substance  as  an  adjuvant  to 
food  were  surprising.  The  most  interesting  feature  was  that  tropon 
was  excellently  well  borne  by  patients  suffering  from  an  impaired 
digestion.  Tropon  seems  to  be  particularly  valuable  on  account 
of  its  small  bulk  and  its  substituting  completely  the  albumen  in 
other  foods.  That  such  a  substance  should  be  of  value  in  the 
treatment  of  consumptives  seemed  evident.  Through  the  cour- 
tesy of  Professor  Finkler  I  received  a  quantum  of  tropon  several 
months  ago,  with  which  I  began  my  experiments  in  feeding  tuber- 
culous patients.  The  results  were  so  encouraging  that  I  wrote  for 
an  additional  supply.  I  selected  patients  with  whom  I  had  had  un- 
usual difficulty  in  increasing  their  weight,  with  some  among  them 
on  account  of  their  aversion  to  fats.  To  sinnmarize  the  results 
obtained,  I  may  say  that  with  from  one  to  two  ounces  per  day  the 
average  gain  in  twenty  days  was  about  one  pound  and  a  half,  in- 
cluding one  case  with  negative  results.  I  must,  however,  add  that 
these  patients  were  mostly  ambulant.  In  Weicker's  sanaUnium  in 
Goerbersdorf,  where  patients  in  all  stages  of  the  disease  are  ad- 
mitted, from  out  of  eighteen  cases  fifteen  responded  to  the  treatment, 
gaining  in  the  average  2^  pounds  in  four  weeks.  The  1  lativcly 
better  results  obtained  in  the  sanatorium  must  be  ascribed  to  a 
better  supervision  and  a  more  regular  administration  of  ti  ■  tropon 
than  is  possible  with  ambulant  patients.  Tropon  has  smce  been 
extensively  used  with  satisfactory  results  in  the  clinics  of  von  Ley- 
den  and  Senator  in  Berlin;  Schmelinsky  and  Klein  in  Hamburg. 
It  can   be  administered  with  mush,  thick  soup,  cocoa,  chocolate. 


'  "  Kiweissnahning  und  N'ahrungseiweiss,"  "  Deutsche  med.  Wocliensclirift,"  i8().S, 
No.  17. 


DIETETIC   TREATMENT   OF   PULMONARY   TUBERCULOSIS. 


^43 


milk,  mashed  potatoes,  rice,  sago,  tapioca,  etc.  It  must  be  borne 
in  mind  that  tropon  is  not  soluble  in  water,  and  consequent!}'  falls 
to  the  bottom  in  clear  liquids,  coffee,  and  thin  soups,  and  when 
taken  with  such  it  must  be  constantly  stirred.  It  can  be  ad- 
vantageously taken  with  the  yolk  of  an  egg  and  some  sugar. 
For  those  of  my  ambulant  patients  who  have  not  the  conveniences 
of  home  life,  I  prescribe  the  tropon  to  be  taken  by  the  aid  of  a 
wafer  (a  teaspoonful  at  a  time). 

Considering  that  tropon  is  really  an  able  substitute  for  the  albu- 
men in  other  foods,  that  it  rarely  causes  digestive  disturbances, 
that  it  can  be  taken  for  a  long  period  of  time  without  aversion,  and 
that  it  is  excessively  cheap,  we  may  look  upon  this  new  product  as 
a  most  valuable  adjuvant  in  the  dietetic  treatment  of  phthisical 
patients. 


Ik-  J 


1 .    I. 
.*-  •  ■*. 

J.  K 


^ff»'^ 


i 


CHAPTKR   XVII. 


SYMPTOMATIC     TREATMENT    OF 

CULOSIS. 


PULMONARY    TUBER- 


Malmitri- 
tioii  mill 
anorexia. 


The  hygienic  and  dietetic  treatment  in  the  closed  establishment, 
combined  with  careful  aiiro-  ard  hydro-therapy,  has  been  described 
in  the  preceding  pages.  This  treatment  is  applicable  to  the 
average  case  of  pulmonary  tuberculosis,  but  there  are  cases  in 
which  this  alone  will  not  suffice.  There  are  patients  who  present 
a  disease  with  one  or  several  symptoms  more  pronounced,  and 
which  will  not  yield  to  the  hygienic  and  dietetic  measures  alone, 
or  to  the  routine  aero-  or  hydro-therapeutic  treatment ;  for  these 
we  must-  institute  a  judicious  symptomatic  treatment. 

A  very  much  impaired  nutrition,  with  a  lack  of  assimilative 
power,  should  not  be  treated  by  forced  alimentation,  but  by  rest, 
at  first  in  bed  and  later  on  the  veranda ;  regular  massage ;  frequent 
administration  of  small  quantities  of  food,  consisting  of  very  easily 
digested  substances,  such  as  scraped  or  finely  chopped  raw  beef, 
toast  (fresh  bread  should  never  be  given  when  there  is  any 
digestive  trouble),  milk  pure  or  with  egg  in  the  form  of  egg-nog 
(two-thirds  of  a  glass  of  milk,  the  yolks  of  one  or  two  fresh  eggs, 
one  or  two  teaspoonfuls  of  good  cognac  or  »\'hiskey,  and  enough 
sugar  to  suit  the  taste),  bouillons,  soups,  etc.  The  yolks  of  fresh 
eggs  I  recommend  to  all  weak  consumptives.  Taken  raw,  beaten 
with  a  little  sugar  or  .salt,  several  times  a  day,  they  seem  to  act  by 
their  nuclein  as  valuable  material  in  the  reproduction  of  new 
tissue-cells.  The  yolks  of  fresh  eggs  will  often  be  retained  when 
the  stomach  apparently  tolerates  nothing  else.  At  times  the 
anorexia  consists  of  a  simple  aversion  to  warm  meat ;  in  such 
cases  no  "rging  will  help,  and  the  best  thing  to  do  is  to  replace 
warm  dishes  by  cold  meats  appetizingly  served. 

Some  patients  may  be  able  to  take  a  meal  in  the  open  air  when, 
seemingly,  they  cannot  do  so  in  the  dining-room.  Though  this 
form  of  anorexia  is  evidently  of  purely  psychic  origin,  it  is  well 
to  be  indulgent  in  this  respect,  for  nothing  should  be  left  undone  to 

244 


SYMPTOMATIC   TREATMENT   OF   PULMONAKV   TUBERCULOSIS.      245 

make  the  pulmonary  invalid  eat.  As  has  been  said  already,  the 
salvation  of  the  patient  lies  in  good  nutrition.  Where  there  is 
anorexia,  the  cause  of  which  cannot  be  determined,  it  will  be 
necessary  to  change  the  menu  often.  Have  the  patient  eat  little 
at  the  time  until  he  and  his  physician  have  discovered  something 
which  may  serve  as  a  stand-by  in  the  dietetic  treatment  of  the 
disease.  To  build  up  the  system  cod-liver  oil  may  be  given  when- j,,,^,  ,|^,g^ 
ever  the  stomach  can  support  it.  A  good  method  for  its  adminis-"''- 
tration  is  that  of  Ericemoret,  which  is  to  mix  it  as  follows : 

B .     Cod-liver  oil, 12  fluidounces 

Syrup  of  tolu, 6  fluidounces 

Tincture  of  tolu, 12  drops 

Oil  of  cloves, 2  drops. 

At  the  moment  of  administration  the  mixture  is  to  be  well  shaken, 
and  a  tablespoonful  taken  two  or  three  times  daily.  Taken  thus, 
the  taste  of  the  aromatic  syrup  only  remains  after  the  ingestion  of 
the  oil.  In  younger  subjects  and  children,  cod-liver  oil  seems  to 
have  a  particularly  gratifying  action. 

The  various  malt  preparations,  as  maltzyme,  malt-extract,  and 
maltine,  may  be  given  with  benefit  in  either  the  pure  state  or  com- 
bined with  cod-liver  oil  or  hypophosphites.  Next  in  efficacy  come 
the  arsenical  preparations,  the  strychnias,  the  irons  (ferratine  is 
especially  well  borne  by  phthisical  invalids),  and  the  phosphates. 

Iodoform  has  given  much  satisfaction  in  the  hands  of  many 
phthisio-therapeutists  such  as  Flick, ^  Daremberg,'^  Ransom, ^  de 
Renzi."*  It  has  been  recommended  for  nearly  all  degrees  of 
phthisis,  and  given  as  inhalation  in  the  form  of  one  part  of  iodo- 
form to  ten  parts  of  ether  (twenty  minims  of  the  mixture  for  each 
inhalation  with  respirator-inj-aler).  It  is  administered  as  p  lis, 
according  to  the  following  formula: 

li.      Iodoform, gr.  iss  loHnfoim. 

Codeix,      gr-   ') 

Ext.  cascane, gr.  J4. 

M.  et  ft.  pil.  j. 


'    Flick,  "  A  Further  Report  011  the  Treatment  of  Tuberculosis  by  Iodoform  Inunc- 
tions," "  The  Medical  News,"  March  2,  1S92. 

-   Daremberg,  "  Traitement  de  la  Phtisie  I'ulmonaire,"   Paris,  1S93. 
'   Ransom,   "The  Treatment  of  Phthisis,"   London,  1896. 
*  De  Renzi,  Naples, "  The  Lancet,"  December,  1897. 


1M' 


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if^t 

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m 

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f»^ 

k 

M'^' 

i 

Si.' 

f. 

^' 

'li 

: 

246 


PULMONARY   TUBERCULOSIS. 


^i   i 


Creosote, 
Kuniacol, 
etc. 


Flick  gives  iodoform  as  an  inunction.  De  Renzi's  method  of 
its  administration  is  especially  recommendable.  If  the  patient  is 
suffering  from  diarrhoea  he  gives  the  following  prescription : 

R .     Iodoform, gr.  xxx 

Tannin,  ... gf-  '"• 

M.  and  divide  into  forty  cachets. 
From  two  to  four  cachets  daily. 

If  there  is  a  tendency  toward  constipation,  Professor  de  Renzi 
replaces  the  tannin  by  naphthalin. 

The  various  modern  preparations  of  creosote  and  guaiacol  seem 
in  most  cases,  when  given  in  small  doses,  to  exert  a  favorable  in- 
fluence on  the  general  condition  of  the  patient.  I  prefer  to  give 
the  creosote  in  milk,  beginning  with  two  or  three  drops  thrice 
daily,  gradually  ini,  ~''".g  to  about  twenty- five  drops  per  day. 
The  moment  there  is  the  slightest  digestive  disturbance  I  stop  the 
creosote ;  and  if  I  then  find  that  the  patient  does  as  well  without  as 
with  it,  I  do  not  recommence  its  administration  again.  In  order 
to  protect  the  consumptive  invalid  as  far  as  possible  from  his 
greatest  foe,  dyspepsia,  I  follow  this  rule  with  all  medicinal  reme- 
dies, new  or  old. 

The  creosotal  (creosote-carbonate)  is  seemingly  more  easily 
borne  than  the  creosote  It  has  been  strongly  recommended  by 
von  Leyden,  of  Berliii,  and  at  the  last  Congress  for  the  Study  of 
Tuberculosis  in  Paris  Dr.  S.de  Planzoles  submitted  a  very  favorable 
report  on  its  use  in  nearly  all  stages  of  pulmonary  tuberculosis. 
The  creosotal  contains  ninety  per  cent,  of  its  weight  of  pure 
creosote.  It  can  be  taken  pure  or  as  an  emulsion  with  the  yolk 
of  an  egg,  with  milk,  or  with  cod-liver  oil.  For  an  adult  fifty  to 
sixty  minims  may  be  given  two  or  three  times  daily  ;  this  should, 
however,  be  considered  a  maximum  dose.  It  is  best  in  all  cases 
to  begin  with  small  doses,  as,  for  example,  five  to  ten  drops  per 
diem  ;  then  gradually  increase  and  return  again  to  smaller  doses. 

According  to  Stubbert's  report,^  of  1898,  ichthyol  prepared  as 
enteric  pills,  two  grains  each  (three  to  fifteen  per  day),  has  been 
used  with  considerable  success  at  the  Liberty  Sanitarium. 

Guaiacol  has  also  found  favor  with  some  phthisio-therapeutists 
as  a  valuable  remedy  in  tuberculosis.     It  has  the  advantage  over 


*  "  Sanitarium  Treatment  of  Pulmonary  Tuberculosis,"  "St.  Louis  Med.  Gazette," 
December,  1898. 


SYMPTOMATIC  TREATMENT  OF  PULMONARY  TUHERCULOSIS.      247 

creosote  that  h  <s  less  irritating  and  that  it  deranges  the  digestion 
more  rarely  than  the  former.  It  is  best  given  diluted  with  milk, 
beginning  with  five  drops  three  times  daily,  gradually  increasing 
this  dose  to  fifteen.  The  patients  who  have  too  great  a  dislike  for 
its  peculiar  and  unpleasant  odor  can  sometimes  be  induced  to  take 
guaiacol  in  capsules.  Goldmann,  in  the  "Riforma  Medica"  of 
December  22,  1898,  recommends  guaiacol  and  ichthyol  in  the 
following  combination: 

K  •     Carbonate  of  t;uaiacol, 

Sulphichthyolate  of  ammonium, of  eacli  225  grains 

Pnre  glycerine 600  minims 

Peppermint-water 150  minims. 

M.     Twenty  to  thirty  drops  to  be  taken  daily. 

If  even  the  guaiacol  is  not  well  tolerated  by  the  stomach, 
Bouteron's*  guaiacol  enema  or  suppositories  may  be  advantage- 
ously applied  : 

R  .     Guaiacol  (in  crystals  melted  at  alow  temperature),  .    .     gr.  v-xv 

Olive  oil, ^iss-^ij. 

Inject  at  a  temperature  of  about  90°  F. 

li  .     Cjuaiacol, gr.  vj-xv 

Cocoa-l)ulter, gij. 

For  two  suppositories,  to  be  applied  within  twenty-four  hours. 

Ordinary  salt  has  often  been  of  value  to  me  as  an  alterant  in  the 
treatment  of  pulmonary  tuberculosis.  While  it  may  be  given  in 
solution  as  an  inhalation,  it  is  most  easily  and  effectually  adminis- 
tered in  large  doses  with  the  consumptive's  daily  meals.  Drozda^ 
ascribes  to   chloride    of    sodium    a    remarkably   stimulating   and  chloride 

....  rr  1  1  Ti       •  1  1   ■         T  ofsodinni 

ehmmating  effect  on  the  pulmonary  secretions.     Besides  this,  I  .imi  intonse 

1  111  1        •  •  /■   1  ■   •  /-        1  •  1  niineializa- 

have  no  doubt  that  the  ingestion  of  large  qaantities  of  salt  aid  to  Hon. 
quite  a  considerable  degree  in  the  calcareous  transformation  of 
tuberculous  lesions. 

Dimitropol's  intense  mineralization^  should  also  be  mentioned 
here  as  analogous  to  the  chloride  of  sodium  treatment.  The 
following  is  his  method  of  administration  of  chloride  or  phosphate 
of  sodium  or  the  tribasic  phosphate  of  calcium.     The  patient  is 


>   "  Prcsse  Midicale,"  1899,  No.  13. 

-   Drozda,   "  Cirundziige    einer  rationellen    Phthisiothera)  ie,"  XII.   Intcrnationaler 
Congress. 

■■'  "  Gazette  hebdomadaire  de  niedecine  el  chirurgie,"  July  17,  1S98. 


!, 


i.f-  ■ 


^  is 

kill 

M 


248  PULMONARY   TUBERCULOSIS. 

given,  daily,  for  thirty  or  forty  days,  each  morning,  a  nutritive 
mixture  composed  thus: 

U  •     Yolks  of  eggs, 4  or  5  ill  number 

Tepsin 15      grains 

Hot  tiiill<, 12^  ounces  ; 

the  whole  being  well  beaten  up  for  five  minutes  and  flavored, 
according  to  taste,  with  a  little  vanilla. 

Ten  minutes  later  a  slice  of  bread  and  butter,  well  salted  to  the 
extent  of  at  least  half  a  teaspoonful  of  kitchen-salt,  is  given.  When 
the  patients  are  very  wasted,  there  should  be  administered,  in  addi- 
tion, nutrient  enemata  composed  as  follows: 

B  .     Yolks  of  eggs, 4  in  nuinber 

Liquid  peptone, 375  grains 

Chloritle  of  sodium, 75  grains 

Hot  concentrated  bouillon, 1 200-1500  grains. 

This  enema,  well  beaten  up,  should  be  slowly  introduced  by  means 
of  an  irrigator.  Each  enema  should  be  preceded  by  an  evacu- 
ating enema.  The  patient  also  takes,  daily,  from  ninety  to  one 
hundred  and  eighty  grains  of  tribasic  phosphate  of  calcium  and 
from  thirty  to  sixty  grains  of  phosphate  of  sodium,  as  in  the 
following  formula  : 

K  .     Tribasic  phosphate  of  calcium, 30       grains 

Phosphate  of  sodium, 7j^  grains; 

in  each  powder.     From  three  to  six  daily. 

After  each  meal  there  is  given,  in  half  a  glass  of  water,  from 
two  to  four  teaspoonfuls  of  hydro-chlorophosphate  of  calcium  in 
ten  per  cent,  solution. 

All  the  drugs  enumerated  should  be  administered  first  in  smaller 
doses,  increasing  gradually  for  forty  days ;  toward  the  end  of  this 
tiine  it  is  necessary  to  diminish  the  doses,  to  continue  with  smaller 
doses  for  six  months,  and  to  recommence  later  with  intermissions 
as  may  be  deemed  necessary,  guided  by  the  tolerance  of  the 
patient. 

Further,  there  is  prescribed  daily,  for  thirty  or  forty  days,  two 
hundred  and  twenty-five  grains  of  common  salt  mixed  with  food 
already  salted  in  the  ordinary  culinary  preparation.  It  is  neces- 
sary for  the  patients  to  take,  indefinitely,  from  ninety  to  one 
hundred  and  twenty  grains  of  salt  daily. 


SYMPTOMATIC  TREATMENT  OF  PULMONARY  TUBERCULOSIS. 


>49 


Resides  this  treatment  Dimitropol  administers,  daily,  eighteen 
ounces  of  meat,  a  quart  of  mili<,  three  eggs  prepared  to  the  patient's 
taste,  fish  and  fresh  vegetables  in  habitual  quantity. 

Wherever  there  is  a  great  difficulty  in  nourishing  the  patient,  it 
seems  to  me  that  this  treatment  is  well  worth  trying.  Of  course, 
a  patient  submitted  to  the  ingestion  of  such  large  quantities  of 
salt  should  be  closely  watched  ;  for,  doubtlessly,  there  will  be 
individuals  who  cannot  take  half  the  quantity  of  salt  prescribed 
without  intestinal  disturbances. 

The  old  idea  of  ingestion  of  the  fresh  blood  of  bullocks  as  an  biooU 
anti-phthisical  remedy  has  been  recently  revived  by  Dr.  Whit-*^"^ 
taker.^  He,  however,  recommends  it  administered  in  form  of 
enemata.  To  each  quart  of  blood  he  adds  half  an  ounce  of  bicar- 
bonate of  sodium  and  sugar  of  milk  and  one  grain  of  common 
salt.  Two  pints  of  a  m'  :ture  consisting  of  equal  parts  of  water 
and  blood  are  thrown  high  up  in  the  rectum.  Dr.  Whittaker  has 
found  marked  increase  in  weight  and  gain  in  nutrition  to  follow 
the  repeated  use  of  such  blood-enemata  in  tuberculosis. 

As  a  general  tonic  the  following  composition  has  given  me  much 
satisfaction  : 

B ,     Tiiict.  nucis  vomicre,    . 3  ij 

Tinct.  cinchonas, 

Tinct.  calumlnv, aa    _^j 

Tinct.  gentiana;, q.  s.  ad    ^^iv. 

M.     SlG. — One  teaspoonful  in  a  little  water  before  each  meal. 


i  } 

! 


A  milk  diet  often  helps  to  bridge  over  a  period  of  anorexia ; 
but  some  people  can  not  or  will  not  take  milk.  Raw  eggs  stirred 
into  substantial  soups  may  be  made  to  take  its  place.  Koumiss  miiu, 
(fermented  mares'  or  cows'  milk)  is  also  a  most  valuable  substitute  tic. 
whenever  there  is  an  aversion  to  milk  in  its  natural  state.  In 
absolute  anorexia  one  must  endeavor  to  find  out  the  cause  by  an 
analysis  of  the  gastric  juice,  and  direct  the  medication  accordingly. 
A  good  preparation  for  excessive  acidity  of  the  stomach  is  five 
grains  each  of  bismuth,  bicarbonate  of  sodium,  salol,  or  benzo- 
naphthol,  to  be  taken  before  meals.  Not  infrequently,  however, 
this  hyperacidity  seems  to  be  of  a  purely  nervous  origin,  and 
persuasion  and  suggestion  or  electricity  will  prove  the  best 
remedies.     In  undetermined  troubles,  to  wash  out  the  stomach  a 


*   "Practitioner"  ;  "Canada  Lancet,"  January,  1899. 


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PULMONARY   TUBERCULOSIS. 


meat- 
powder. 


Dilatation 
of  the 
stomach. 


DiarrhiL'a. 


few  times  often  gives  relief.  At  times,  however,  it  may  b  .come 
necessary,  in  order  to  convince  the  patient  of  his  digestive  power 
or  not  to  let  him  starve,  to  resort  to  Debove's  method  of  tube- 
feeding.'  His  poudre  aliinentairc,  or  meat-powder,  is  prepared  in 
the  following  manner :  Beef  is  taken  and  all  the  fat  possible 
removed,  and  also  the  tendons.  It  is  hashed  rather  coa:"seiy  and 
spread  on  plates,  to  be  dried  in  an  oven  at  a  temperature  '>f  194°  F. 
When  the  meat  has  dried  hard,  it  is  ground  in  a  moilar  at  d  then 
strained  through  a  fine-silk  sieve.  The  powder  thus  oL'^a  ned  is 
impalpable  and  will  keep  indefinitely  if  preserved  from  dampness. 
It  represents  four  times  the  weight  of  fresh  meat.  The  best  vehicle 
for  the  introduction  of  meat-powder  is  bouillon,  to  which  may  be 
added  the  whites  and  the  yolks  of  two  eggs,  previously  beaten. 

Other  digestive  troubles  may  often  be  successfully  treated  by 
simple  and  careful  dieting  and  the  judicious  administration  of 
pepsin  or  pancreatine  preparations.  Dilatation  of  the  stomach,  for 
example,  often  yieldsrapidly  tothedry  dietso  highly  recommended 
by  Bouchard,  of  Paris.  Acute  attacks  of  diarrhoea,  if  not  due  to 
tuberculous  intestinal  lesions,  are  best  treated  by  first  cleansing 
the  intestinal  canal  and  then  giving  the  patient  appropriate  food, 
such  as  cocoa,  toast,  eggs,' rice,  mucilaginous  soup,  and  Bordeaux 
wine  with  arrowroot.  If  the  diarrhoea  is  due  to  tuberculous 
intestinal  lesions,  the  case  is  more  difficult.  Mere  diet  does  not 
suffice  to  stop  it,  and  even  large  doses  of  opium  and  bismuth  have 
no  lasting  effect.  Hot  claret  with  cinnamon,  also  tannic  or  gallic 
acid  in  large  doses,  sometimes  give  more  lasting  relief.  As  a 
medicinal  remedy  for  chronic  diarrhcL'a  in  tuberculosis.  Dr.  de 
Renzi's  combination  of  tannin  and  iodoform,  as  cited  above  when 
speaking  of  iodoform,  should  be  recalled. 

Phthisical  patients  suffering  from  frequent  diarrhoea  should  keep 
the  abdomen  warmly  covered.  They  should  avoid  such  articles  of 
food  as  cabbage,  salads,  sweetmeats,  or  substances  which  their 
experience  has  taught  them  tend  to  increase  the  frequency  of 
stools.  They  should  adhere  .strictly  to  the  anti-diarrhcuic  diet 
just  described  for  acute  attacks.  In  the  severer  forms  of  diarrhoea, 
absolute  rest  in  bed  must  be  insisted  upon. 

It  should  be  impressed  upon  the  patient  that  his  bowels  must 


-1 


'  Diibove,  .M.,  "  Kecherches  sur  rAlimentation  arlilicielle,  la  Suralimentation,"  etc. 
Communication  faite  a  la  Socl6t6  med.  des  HOpitaux.     Stance  du  14  Avril,  I.SSz. 


!«! 


SYMPTOMATIC  TREATMENT  OF  PUI.MONAKV  TUHERCULOSIS.      25  I 

move  freely  once  every  liay.  Any  tendency  to  constipation  hecnnsiipa 
should  at  once  report  to  the  physician.  Great  effort  during  the 
act  of  defecation  maybrin<^  about  a  severe  h;cnioptysis  or  cause  the 
development  of  hemorrhoids.  Carlsbad  salt  and  the  California  cas- 
cara  sagrada  are  favorite  remedies  in  the  Euro[)ean  sanatoria  when 
prunes  and  other  fruits  are  of  no  avail.  For  the  more  obstinate 
forms  of  constipation  in  fairly  .strong  patients  the  judicious  adminis- 
tration of  hydrargyrum  chloridum  mite — as,  for  example,  ten  grains 
in  fractional  doses  of  one  grain  every  hour,  with  the  sugar  of  milk- 
as  vehicle — renders  often  valuable  services.  Not  to  weaken  the 
patient  unnecessarily  I  have  him  stop  the  calomel  powders  the 
m  ment  he  has  had  a  free  evacuation,  which  in  many  cases  is 
tifected  by  the  fifth  or  sixth  dose.  I  do  not  favor  too  frequent 
enemata :  they  tend  to  lessen  the  contractile  power  of  the  large 
intestines.  At  times  a  glycerine  suppository  will  do  the  work  of 
an  evacuating  enema.  If  the  constipation  takes  a  chronic  char- 
acter, abdominal  massage  is  usually  resorted  to  with  good  results. 
The  application  of  the  wet-pack  over  the  abdominal  cavity  for  a 
few  hours,  followed  by  a  gentle  friction  with  alcohol,  also  rarely 
fails  to  help. 

Painful  coughs  seem  best  relieved  by  small,  repeated  doses  ofcouKh. 
codeine  in  solution,  but  the  dry  cough,  which  is  often  the  result  of 
habit,  and  where  there  is  really  nothing  to  expectorate,  should  be 
suppressed  by  discipline.  Dettweiler  tells  his  patients  that  to 
cough  in  public  without  cause  is  scratching  the  throat  because  it 
tickles,  and  that  it  is  as  ill-mannered  as  scratching  one's  head  in 
public  when  it  itches.  Sips  of  cold  water,  orange-juice,  or  milk, 
small  pieces  of  ice  or  tablets  of  Iceland  moss  (cetraria),  will  help 
to  overcome  tickling  sensations  in  the  throat  until  the  patient  has 
fully  become  master  of  the  cough.  Holding  the  breath  for  a  few 
seconds  will  often  help  also.  It  is  really  wonderful  how  much  it 
is  possible  to  accomplish  in  this  respect  by  discipline.  In  Falken- 
stein  I  have  dined  for  weeks  with  a  hundred  and  more  consump- 
tives in  one  large  dining-hall,  and  it  was  a  rare  occurrence  to  hear 
a  single  cough  during  the  dinner-hour. 

To  relieve  the  not  infrequent  morning  attacks  of  coughing,  a 
glass  of  hot  water  with  some  lemon-juice,  with  but  little  or  no 
sugar,  or  with  five  to  ten  drops  of  the  ammoniated  spirit  of  anise 
(liquor  ammonii  anisatus),  often  suffices.  Occasionally,  it  becomes 
absolutely  necessary  to   give  expectorants  regularly  to  relieve  a 


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252  PULMONARY  TUBERCULOSIS. 

distressing  cough  and  the  tenacious  expectoration.     Tlie  following 
prescription  has  rendered  me  good  service  in  most  such  cases : 

li .     Codeinw, gr.  vj-viij 

Acidi  sulphurici  (iiluti f^iss 

Glycerini, 

Aqua"  laurocerasi aft  f 5J 

Syr.  pmni  virginiana; f^ij 

Syr.  tolutani,      ...        q.  s.  ad   f^vj. 

M.  SiG.  —  A  teaspoonful  whenever  the  cough  becomes  distressing;  more  than  six 
t'^aspoonfuls  should,  as  a  rule,  not  be  taken  in  twenty-four  hours. 

At  times  I  change  this  prescription  for  Murrell's  cough-mixture, 
which  is  also  very  good.     It  is  as  follows : 

R .     Co<leinw,        gr.  iv 

Acid,   hydrochlor.  dil., Tl\,xxx 

Spirit,  chloroformi, 3 'ss 

Syrup,  litnonis,      ^j 

.\quw, q.  s.  ad  ^^^iv. 

M.     Siu. — One  teaspoonful  as  occasion  demands. 

In  a  number  of  cases  I  have  tried  the  new  remedy,  heroin, 
recommended  by  Dreser  and  Floret  in  the  "  Therapeutische 
Monatshefte  "  of  September,  1898,  and  by  Manges  in  the  "  New 
York  Medical  Journal"  of  November  26,  1898.  It  has  given 
satisfaction  in  quite  a  number  of  cases,  relieving  dyspnoeic  sensa- 
tion and  seemingly  allaying  the  irritating  cough.  I  have  given  it 
in  tablet  i"uim  as  well  as  in  solution,  but  in  smaller  do.ses,  as 
recommended  by  Manges.  One-sixth  to  j]y  of  a  grain,  taken 
several  times  during  the  day,  seems  to  render  the  patient  drow.sy 
and  sleep;^  I  give  y^y  to  1^^  of  a  grain,  preferably  in  solution.  I 
have  founu  diluted  sulphuric  acid  just  as  good  a  solvent  as 
acetic  acid,  recommended  by  Manges.  To  replace  the  codeine  by 
three  grains  of  heroin  in  the  six  ounces  of  cough-mixture  given 
above  will  render  good  service.  Vv'lien  the  cough  does  not  yield 
to  these  medications,  or  when  there  is  a  marked  bronchorrhoja, 
daily  intratracheal  injections  of  twenty  minims  of  the  following 
liqtiid  often  give  relief: 

H  .      Guaiaiiil , 

Mentlu)!, a;l  rr^x 

<  )1.  oliv., gj. 

If  violent  coughing  spells  cannot  be  repressed,  to  tie  a  wide 
flannel  band  around  the  chest  will  lessen  the  painfid  concu.ssions. 


SYMPTOMATIC  TREATMENT  OF  PULMONARY  TUHERCULOSIS.   253 

Vomiting  in  consumptives  is  relatively  seldom  due  to  digestive  vomiting, 
troubles,  but  is  usually  due  to  the  reflex  action  brought  about  by 
coughing  spells.  So,  if  digestive  derangements  can  be  excluded, 
to  keep  absolutely  quiet  after  eating  and  control  approaching 
attacks  of  coughing  as  above  indicated,  will  prove  the  best 
remedies. 

Besides  the  pains  in  the  side,  of  which  we  will  speak  in  connec- 
tion with  pleurisy,  tuberculous  patients  suffer  intensely  at  times 
from  intercostal  neuralgia.  Hot-water  compresses,  frequently  intercostal 
repeated,  or  the  heating  compress,  which  differs  from  the  chest 
compress  described  on  page  254  by  placing  between  the  linen  and 
the  flannel  some  oil-silk  or  other  impermeable  material,  will  render 
good  service.  When  the  suffering  becomes  unbearable  in  spite  of 
local  applications,  the  subcutaneous  injection  of  ^i  of  a  grain  of 
morphine  at  the  seat  of  pain  should  be  given.  But  before  I 
resort  to  opiates  I  invariably  trv  a  counter-irritant.  It  often  gives  f-"""'"";''- 
instant  relief,  and  is  of  value  in  nearly  all  the  stages  of  the  dis-^.V'^'l^'^'-'^"'- 
ease.  The  counter-irritants  seem  to  draw  from  the  delicate  respir- 
atory and  circulatory  organs  countless  dangerous  micro-organisms 
into  the  less  delicate  cellular  tissue,  where  by  the  action  of  these 
irritants  the  number  of  the  phagocytic  white  corpuscles  has  been 
increased;  thus  an  actual  destruction  of  pathogenic  microbes  is 
brought  about  by  the  simple  mustard  plaster,  the  old-fasL.oned 
dry-cups,  or  the  "  points  de  feu  "  (ignipuncture). 

Counter-irritants  as  a  means  of  producing  revulsion  in  chronic 
pulmonary  tuberculosis  have  become  of  late  somewhat  out  of  use, 
especially  in  this  country.  I  fear  their  therapeutic  value  has  been 
underestimated  in  the  eager  search  for  something  specific.  In 
France,  counter-irritants  are  yet  quite  extensively  resorted  to,  espe- 
cially in  hospital  practice.  In  the  "  Archives  Cliniques  de  Bor- 
deaux," Arnozan  has  recent. y  taken  up  the  study  of  the  influence 
on  the  kidneys  of  the  application  of  cantharidized  blisters  to  the 
thorax.  The  patients  selected  were  only  those  with  normal  urine. 
The  latter  was  again  tested  after  the  application  of  the  blister  and 
it  had  remained  normal  ;  no  other  inconveniences  were  observed 
in  any  case.  As  a  result  of  these  ob.servations,  Professor  Arnozan 
agrees  with  Professor  Grancher,  of  Paris,  that  small  blisters  applied 
repeatedly  are  one  of  the  best  means  of  arresting  the  prt)gress  of 
chronic  pulmonary  tuberculosis,  although  if  the  urine  proves  ab- 
normal in  preliminary  examination,  some  other  "  revulsive  "  than 


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PULMONARY   TUBERCULOSIS. 


cantharides  should  be  employed.  Whenever  a  strong  revulsion  is 
indicated,  and  the  patient's  fear  of  the  hot  iron  can  be  overcome, 
I  give  ignipuncture  the  preference,  it  being  the  cleaner  and  safer 
"  revulsive."  After  its  application  I  sprinkle  over  the  respective 
region  some  inert  powder  as  a  protective. 

To  prevent  night-sweats  the  patient  should  take  a  glass  of  cold 
milk  with  a  little  cognac  before  retiring;  he  should  never  retire 
hungry,  and  should  always  have  some  light  lunch  on  a  table  near 
his  bed,  so  that  he  may  eat  something  if  he  wakes  in  the  night 
feeling  faint.  Again,  if  the  patient  is  in  the  habit  of  waking  up  at 
a  certain  hour  in  the  morning  bathed  in  perspiration,  he  should 
be  waked  two  hours  earlier  and  given  egg-nog  or  another  light 
lunch.  Sometimes  it  will  be  necessary  to  give  him  a  sponging  off 
with  water  and  vinegar,  or  water  and  lemon-juice,  and  the  admin- 
istration of  atropine,  agaricine,  etc.,  also  may  be  indicated.  But 
once,  when  all  remedies  had  failed,  I  resorted  to  the  following 
hydrotherapeutic  procedure,  which  worked  so  well  that  I  no' • 
"osfs'^'"  prescribe  it  in  most  cases  of  severe  hyperhidrosis,  before,  experi- 
menting much  with  medicinal  agents :  Several  thicknesses  of 
rather  coarse  linen,  folded  in  the  form  of  a  shawl,  or,  better  yet, 
three  different  cloths, — one  narrow  one  for  each  apex  like  a  broad 
shoulder-strap,  and  another  wider  one  to  wrap  around  the  chest, — 
are  soaked  in  water  at  a  temperature  of  about  55°  F.,  wrung 
out  and  then  closely  applied  over  the  apices  and  around  the 
thorax.  A  thick  flannel  band,  somewhat  wider  than  the  com- 
press, is  wrapped  over  this,  and  the  whole  is  fastened  in  place  and 
remains  thus  all  night.  The  1  itient  usually  feels  no  discomfort, 
sleeps  well,  and  sweats  but  slightly,  if  at  all.  In  the  morning 
the  compress  is  removed  and  the  chest  and  shoulders  are  rubbed 
thoroughly  dry.  If  the  consumptive  is  relatively  strong  and 
experieii'  c  has  demonstrated  to  the  attending  physician  that  an 
occasional  sweat-bath  does  not  exhaust  the  patient  too  much,  and, 
on  the  contrary,  lowers  his  temperature  and  improves  his  general 
condition,  this  method  of  combating  a  hyperhidrosis  is  perfectly 
justified.  Through  the  sweat-bath  the  excretory  action  of  the 
skin  is  considerably  increased  and  a  larger  quantity  of  toxine  thus 
more  rapidly  eliminated. 

Pulmonary  hemorrhage  is  one  of  the  most  important  symptoms 
to  be  considered  in  the  treatment  of  consumption.  We  cannot 
here  enter  into  the  pathological   significance  of  the  various  types 


SYMPTOMATIC  TREATMENT  OF  PULMONARY  TUBERCULOSIS. 


^55 


and  degrees  of  hemoptysis,  from  almost  imperceptible  bloody 
expectoration  to  a  profuse  flow  of  bright-red  or  dark-colored 
blood,  at  times  from  mouth  and  nose  at  once.  When  called  to  see 
a  patient  with  a  considerable  hemorrhage,  it  is  not  always  easy  to 
say  whether  it  is  due  to  a  congestive  or  an  ulcerative  process,  and 
I  really  do  not  think  that  the  treatment  can  differ  very  much.  In 
profuse  bleeding,  absolute  rest  is  the  all-important  indication.  The 
patient  is  not  allowed  to  talk  and  should  be  placed  in  a  semi- 
recumbent  position.  He  should  be  enjoined  to  refrain  from  an 
attempt  to  hold  back  the  flow  of  b'ood.  Suffocation  or  ensuing 
pneumonia  is  to  be  feared  when  such  attempts  are  made.  All 
persons  not  needed  in  the  room  should  leave,  and  everything 
should  be  kept  as  quiet  as  possible.  The  physician  will  have  at 
his  disposal  four  important  remedies, — viz.,  morphine,  ergotine, 
atropine,  and  hydrastis  canadensis, — all  of  which  he  may  need 
before  being  able  to  obtain  a  stoppage  of  the  flow  of  blood. 
Starke'  and  Solly  recommend  the  hypodermic  injection  of  large 
doses  of  atropine  (J^  of  a  grain)  in  all  serious  cases,  partic- 
ularly in  those  in  which  ergot  has  proved  a  failure.  Nitro- 
glycerine in  one-half-drop  doses  of  one  per  cent,  alcoholic  solution 
every  half-hour  has,  in  the  hands  of  Dr.  Flick,  of  Philadelphia, 
rendered  excellent  services  as  a  hemostatic  in  hemoptysis.-  In 
the  meantime  the  patient  is  given  small  pieces  of  ice  or  small  sips 
of  ice-water. 

To  give  the  assurance  that  a  pulmonary  hemorrhage  is  in 
itself  not  by  any  means  a  symptom  necessarily  dangerous  to 
life,  and  still  less  excluding  the  possibility  of  a  good  recovery, 
will  have  the  best  effect  on  the  usually  much  alarmed  patient. 
Right  here  I  wish  to  say  that  I  think  Wolff's  '  policy,  to  tell  all 
patients,  even  if  they  never  had  a  hemorrhage,  of  the  possibility 
of  this  occurrence,  will  have,  as  far  as  mental  agitation  and  excite- 
ment are  concerned,  a  most  prophylactic  effect.  Especially  will 
this  be  so  when  the  warning  is  accompanied  by  the  assurance  that 
pulmonary  hemorrhages  are  one  of  the  phases  rarely  absent  in 
the  development  of  the  disease,  and  are  symptoms  which,  while 
needing  careful    attention,   are    not    more  dangerous  than   many 


Hemop- 
tysis. 


SugKestive 
Ireatment 
of  pulino- 
naiy  lieiu- 
onliaHe. 


i^\ 


'  Starke,    "  Phthisis,"  "  Dietetic  and  Ilygienir  Ga/ette,"  March,  1899. 

2  "  Philadelphia  Med.  Journal,"  Ftb.  19,  1898. 

"•  Woltr,  "  Die  modenie  Behandlung  der  I,ungensehwindsucht,"  Wicsi.aden,  1894. 


1 1      ll 


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256 


PULMONARY    TUBERCULOSIS. 


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others.  After  the  injection  of  morphine  or  ergotine  or  atropine  or 
the  administration  of  hydrastis  canadensis,  bags  of  morseled  ice 
may  be  placed  over  the  pv-^-toral  region  of  the  apices.  But  since 
ice  may  not  always  be  had  when  it  is  most  urgently  needed,  and 
the  weight  ot  the  bag  becomes  sometimes  oppressive  to  the  patient, 
the  following  method  of  applying  cold  water  when  in  presence  of 
hemorrhage  of  the  lung  is,  I  think,  well  worth  remembering.  It 
was,  I  believe,  first  instituted  by  Winternitz.  One  procures  the 
water  as  cold  as  possible  and  soaks  in  it  a  part  of  a  sheet  or  a  piece 
of  rather  coarse  linen.  When  rung  out  so  that  it  does  not  drip,  the 
cloth  is  folded  in  the  shap"  of  a  triangle,  placed  clo.sely  over  the 
patient's  chest,  and  is  pressed  into  the  supraclavicular  spaces.  The 
apex  of  the  triangle  reaches  over  the  pit  of  the  stomach  and  the 
base  touches  the  neck.  Whenever  the  compress  becomes  warm  it 
can  be  rapidly  changed  without  disturbing  the  patient's  position. 
The  cooler  and  more  frequent  the  application,  the  more  rapid  is  the 
action  of  the  vaso-constrictors. 

When  the  shock  from  the  hemorrhage  has  been  very  severe  a 
hypodermic  injection  of  ether,  digitaline,  or  caffeine  is  well  indicated. 
I  should  also  suggest  in  cases  of  severe  shock,  as  a  result  of  a  pro- 
fused  hemoptysis,  Kemp's  new  method '  of  recto-irrigation  with 
hot  salt  solutions  (one  teaspoonful  of  chloride  of  sodium  to  a  quart 
of  water  at  a  temperature  of  100°  to  120°  F.)  by  the  aid  of  his 
double  catheter.  The  warmth  thus  conveyed  to  the  body,  and, 
in  audition,  the  absorption  of  the  saline  solution,  will  help  to  bring 
about  a  favorable  reaction.  The  irrigation  can  be  kept  up  for  an 
hour  or  more  without  the  patient  being  inconvenienced.  Brannan- 
recommends  aconite  as  a  direct  cardiac  sedative.  According  to 
the  experiments  of  Andrew^  it  produces  a  fall  in  the  pressure  in 
the  pulmonary  artery. 

Of  the  physical  means  to  control  pulmonary  hemorrhages  I 
desire  yet  to  mention  the  sometimes  very  useful  ligation  of  lower 
and  upper  limbs  to  prevent,  in  a  measure,  the  blood  from  returning 
to  the  lungs.  During  my  visits  to  the  European  sanatoria  I  saw 
some  very  elaborate  and  expensive  instruments  djvised  for  that 


'  Kemp,  "  Intestin-.'i  Hydrotherapy,"  "  Tr-insiut.  of  N.  V.  Academy  <if  Mediciiip," 
I'"el).  3,  189S. 

-  !>raniian,  J.  \V.  "The  'I'leiUii.tiit  of  rulinoiiaiy  llcmorrliage,"  "  X.  \'.  Med. 
Journal,"  vdI.  i  ,  p.  21IS. 

'  Andrew,  llarvciati  lectures;   "  Hritisli  Med.   JDurnal,''  1890,  vdI.  11,  p.  942. 


t 


SYMPTOMATIC    TREATMENT    OF    PULMONARY    TUBERCULOSIS.     257 

purpose  (Assalinische  Schriallen),  but  any  flannel  band,  mufHer.  or 
large  handkerchief  will  answer  the  purpose  just  as  well.  These 
lijrations  of  arms  or  legs  are  made  as  near  the  trunk  as  possible, 
and  just  tight  enough  to  hinder  the  return  of  the  venous  flow,  but 
not  to  compress  the  arterial  pulse.  Every  half-hour  or  so  the 
bands  should  be  loosened,  provided  a  too  painful  compression  of 
some  nerves  or  a  threatening  anjemia  of  the  brain  does  not  demand 
an  earlier  removal  of  the  ligatures.  Under  ordinary  circumstances 
these  constricting  bands  can  be  renewed  after  short  intenals  and 
as  often  as  the  condition  of  the  patient  may  indicate.  A  hot-water 
bag  should,  at  the  same  time,  be  placed  at  the  feet. 

After  the  stoppage  of  an  acute  hemorrhage,  the  administration  After- 

'^^    "  "  treatment. 

of  astringents,  such  as  the  fluid  extract  of  ergot,  or,  better  yet.  gal- 
lic acid  in  ten-grain  doses,  and  of  iced  drinks,  must,  of  c<jiirse,  be 
continued  for  some  time.  Cold  diet,  liquid  or  semi-liquid,  should 
also  be  insisted  on  for  a  while  after  acute  attacks.  The  meals 
should  be  small  but  frequent,  to  attract  the  blood  to  the  alimentary 
canal.  The  patient  should  also  be  instructed  to  refrain  from 
coughing  violently,  to  avoid  a  renewal  of  the  hemorrhage. 

Lastly,  I  wish  to  speak  of  the  value  of  deep,  quiet  respirations  ;  Yi"*^ 
of  course,  without  any  e.xtra  effort  or  movement  of  the  arms. ^'f""''"K- 
When  instituted  an  hour  or  so  after  the  acute  attack  has  subsided, 
two  or  three  deep  respirations  every  thirty  or  si.xty  seconds  will 
hasten  the  complete  cessation  of  the  bloody  expectorations  which 
have  so  frequently  a  tendency  to  become  chronic.  It  is  often 
the  custom  to  continue  the  absolute  rest  necessary  during  the  acute 
attack  too  long.  I  see  in  this  habit  a  certain  danger  of  hypostasis; 
in  fact,  I  think  we  should  permit  a  patient  to  leave  the  bed  or  couch 
a  few  days  after  the  cessation  of  the  hemorrhage  to  take  short 
walks,  according  to  his  strength,  around  the  room  or  on  the 
veranda. 

It  goes  without  saying  that  those  patients  whose  bloody  expec- 
toration is  of  a  distinct  chronic  character,  and  where  the  congestive 
origin  is  evident  and  the  general  condition  is  relatively  good,  should 
rather  be,  as  much  as  possible,  out-of-doors;  and  for  them  respir- 
atory exercises  are  of  special  value.  No  less  an  authority  than  the 
great  immortal  Traube  instituted  this  mode  of  treatment  for  chronic 
hemoptysis  due  to  congestion  of  the  respiratory  organs.  For  the 
same  class  of  patients  the  pneumatic-cabinet  treatment,  persistently 
carried  out,  is  most  valuable  in  arresting  chronic  pulmonarj-  hem- 
17 


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If 

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1 


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liil! 


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If 


Hemo- 
philic 
diathesis. 


Of  (ever 
in  general. 


258 


PULMONAKV    TUBERCULOSIS. 


I'll 


orrhagcs.  The  repeated  but  careful  administration  of  saline  cathar- 
tics also  renders  good  service  in  relieving  the  thoracic  organs  of 
their  congestion. 

All  phthisio-therapeutists  will  occasionally  meet  with  patients 
having  frequent  pulmonary  hemorrhages  which  are  not  at  all  in 
correspondence  with  the  relatively  small  tuberculous  lesion  which 
the  stethoscopic  examination  reveals.  The  only  explanation  in 
such  cases  is  a  hemophilic  diathesis.  A  few  times  I  have  found 
myself  in  the  presence  of  such  cases.  The  usual  anti-hemorrhagic 
remedies  having  failed,  I  resorted  to  a  well-known  remedy  which 
we  are  apt  to  prescribe  if  we  know  of  nothing  better.  I  employed 
the  iodide  of  potassium  to  combat  the  hemorrhagic  diathesis, 
hoping,  if  possible,  to  overcome  through  this  alterant  the  fragility 
of  the  blood-vessels.  I  gave  the  saturated  solution  of  iodide  of 
potassium  at  first  in  five-drop  doses  in  milk,  raising  the  dose  grad- 
ually to  fifteen  drops  three  times  daily  (forty-five  grains  in  twenty- 
four  hours).  In  none  of  my  cases  could  I  discover  a  syphilitic 
history.  Still,  the  result  of  this  treatment  was  most  satisfactory. 
The  intervals  between  the  hemorrhages  became  longer,  and  the 
quantity  of  expectorated  blood  smaller. 

To  combat  fever  in  pulmonary  tuberculosis  requires  close 
study  and  observation.  There  is  the  chronic  type  and  the  acute 
type.  We  will  speak  first  of  the  most  frequent — the  chronic 
form. 

Some  phthisio-therapeutists  recommend  to  have  the  temperature 
of  their  ambulant  or  non-ambulant  patients  taken  by  the  invalid 
himself  every  two  hours.  I  do  not  approve  of  this  method,  for, 
to  my  mind,  it  has  a  tendency  with  many  patients  to  increase  use- 
lessly their  anxiety  and,  ipso  facto,  their  temperature.  Non-ambu- 
lant febrile  patients  should  never  be  allowed  to  take  their  own  tem- 
perature; in  fact,  the  nurse  who  attends  to  this  should  use  all 
possible  tact  not  to  reveal  to  the  patient  any  marked  elevation. 
Mercier's  or  other  so-called  automatic  thermometers  will  ba  of 
good  use  with  this  class  of  patients.  It  seems  to  me  that,  even 
with  a  patient  seriously  ill,  to  take  the  temperature  at  about  eight 
o'clock  in  the  morning,  and  about  one  and  five  o'clock  in  the  after- 
noon, and  at  nine  o'clock  in  the  evening,  would  suffice  as  guidance 
to  the  physician  in  hi.^  antipyretic  treatment.  In  milder  cases, 
taking  the  temperature  at  about  nine  in  the  morning  and  five  in 
the  afternoon  will   be  usually  all  that   is  needed.     In  all  severer 


(J 
5< 


SYMPTOMATIC   TREATMENT   OF   PULMONARY   TUIiERCULOSIS.     259 

cases  the  nurse  sliould  take  tlie  rectal  temperature;  this  method 
is  less  trying  to  the  patient  and  more  exact. 

As  to  the  therapeutic  means  at  our  disposal,  we  will  divide  them 
into  five  classes :  prophylactic,  physical,  dietetic,  general  medi- 
cinal, and  bacterio-medicinal. 

Prophylactic. — A  febrile  patient  arriving  at  a  sanatorium,  hospital,  propiniac- 
or  health  resort,  should  be  put  to  bed,  or  at  least  enjoined  to  takemem^of' 
absolute  rest    on  a  reclining-chair  in  the  open  air  or  in  a  well-  ^^^^' 
ventilated  room,  according  to  the  degree  of  the  fever.     In  private 
practice,  where   the    patient  cannot    be  constantly  observed,   he 
should  be  warned,  even  if  only  in  the  incipient  state  or  on  the 
way  to  recovery,  to  avoid  climbing  many  stairs,  or  other  temper- 
ature-increasing   physical   exercise,    late    dinners,   theatres,    and 
all  exciting  amusements.     Even  the  reading  of  exciting  novels  can 
produce  an  elevation  of  temperature  in  a  tuberculous  invalid. 

Physical. — The   physical  means  at  our  disposal  to  combat  the  physical 
pyretic  condition  in  pulmonary  tuberculosis  are  numerous.     Here,cSat'a 
again,  rest  stands  first,  and,  above  all,  rest  in  bed  in  well-ventilated  thcrapy!'^" 
rooms.     Turban  showed  to  the  Congress  for  Internal   Medicine, therapy, 
held  at  Munich  in  1895,  a  number  of  fever  charts  of  his  phthisical 
patients,  in  whom  he  succeeded  in  reducing  the  temperature  to 
normal  by  prolonged  uninterrupted  rest  in  bed.     Next  in  impor- 
tance comes  the  rest  cure  in  the  reclining-chair  in  the  open  air;  the 
details  of  this  procedure  we  have  already  described  in  the  chapter 
on  aerotherapeutics. 

As  the  next  most  important  physical  means  to  reduce  tempera- 
ture conies  water,  administered  internally,  pure  or  in  the  form  of 
lemonades;  externally,  tepid,  cold,  or  in  form  of  ice.  The  most 
pleasing  of  all  antipyretic  drinks  are  lemon  or  orange  lemonades. 
The  best  method  to  prepare  them  is  as  follows  :  Take  three  table- 
spoonfuls  of  lemon-  or  orange-juice  and  half  of  the  peelings  of  one 
lemon  or  orange;  pour  over  this  ten  ounces  of  hot  water;  before 
putting  the  lemonade  away  to  cool  off,  remove  the  peels  ;  add  a 
few  spoonfuls  of  sugar  to  suit  the  taste. 

The  external  application  of  water  as  an  antipyretic  remedy  is 
most  important.  As  a  rule,  we  may  say,  the  weaker  the  patient 
and  the  higher  the  temperature,  the  more  decidedly  tepid  should 
the  water  be  (68°  to  78°  F.).  For  the  average  patient  sponging 
off — first  partial,  then  entire — with  water  varying  from  55°  to  65°  F. 
is  indicated.     With  timid  patients  the  sponging  off  should  always 


I'  1 


ill! 


1  1 


26o 


PULMONARY   TUBERCULOSIS. 


iJt 


:3C 


M*^l' 


fp 


Dietetic 
treatment 
of  fever. 


be  gradual  and  partial  at  the  beginning,  and  in  the  following  order : 
Hands,  forearms,  face,  throat,  neck,  armpits,  arms,  back,  stomach, 
gluteal  regions;  finally,  the  lower  extremities  from  the  hips  down- 
ward. This  order  of  procedure  has  been  given  by  no  less  an 
authority  than  Winternitz.'  This  sponging  off  should  be  done 
under  cover,  and  with  as  little  exposure  to  the  air  as  possible. 
Each  portion,  after  being  sponged  off,  should  be  rapidly  covered 
without  being  dried,  so  that  the  water,  through  its  evaporation, 
adds  to  the  cooling  effect.  The  effect  of  the  first  application  will 
be  a  guidance  to  the  physician  for  further  procedures.  This 
method  of  applying  the  cold  water  can  be  repeated  three  or  four 
times  daily  until  a  perceptible  reduction  in  the  temperature  is  at- 
tained. In  the  use  of  wet-packs  the  same  gradual  procedure  and 
the  same  care  as  to  the  temperature  should  be  exercised.  I  do 
not  favor  the  entire  enveloping  of  a  phthisical  patient  in  a  cold 
sheet,  but  prefer  the  partial  application  of  compresses  in  the 
reduction  of  temperature  to  either  lower  or  upper  extremities,  or 
the  compress  over  the  chest,  which  has  been  described  more  fully 
on  page  254,  when  speaking  of  the  treatment  of  hyperhidrosis. 
I  resort  to  this  especially  when  the  sponging  off  seems  to  dis- 
turb the  patient  too  much.  I  apply,  for  example,  the  wet-pack 
first  for  a  while  to  the  lower  extremities  ;  next  to  the  upper, 
and  so  on  alternately  every  half-hour.  The  wet-pack  can  be 
also  improvised  with  the  aid  of  a  couple  of  ordinary  towels  as 
pack  and  a  few  larger  Turkish  towels  as  cover.  When  the 
temperature  is  very  high  an  ice-bag  over  the  heart  will  render 
excellent  service  ;  but  still  better  would  be  the  application  of  a 
coil  of  rubber  tubing  over  the  head  or  over  the  heart.  The  water 
can  be  made  as  cold  as  desired,  and  the  rubber  coil  is  not  nearly 
as  heavy  as  the  ice-bag  and  more  easily  applied. 

Dietetic. — This  treatment  in  fever  is,  of  course,  important.  We 
have  touched  already  on  the  subject  in  speaking  of  diet  in  general, 
and  there  mentioned  that  the  febrile  patient  should  eat  when  his 
temperature  is  lowest.  When  the  fever  is  not  excessively  high, 
these  patients  eat  often  with  more  appetite  on  their  reclining-chairs 
on  the  veranda,  where  it  is  quiet,  than  in  the  dining-room,  where 
they  perhaps  cannot  eat  with  the  same  ease  and  comfort.     Cold 


1  Winternitz,  "  Zur  Pathologie  und  Hydrotherapie  iler  Luiigenphlhisie,"  Leipzig  und 
Wien,  1887.  ■ 


m 


SYMPTOMATIC   TREATMENT   OK    PULMONARY   TUBERCULOSIS.     26 1 

dishes  are,  of  course,  also  more  apropos  than  hot  ones  for  any 
fever  patient.  Cold  milk  will  constitute  an  important  factor  in  the 
nutrition  of  febrile  consumptives,  especially  when  they  are  confined 
to  bed.  Other  drinks  of  the  nourishing  kind  which  should  be 
permitted  are  light  beers  and  moderately  alcoholic  wines  largely 
diluted  with  water.  There  are  also  iced  barley-water  and  milk- 
lemonade,  which  are  to  be  recommended.  Here  is  the  receipt  for 
the  latter:  Have  in  readiness  2  ounces  of  sugar,  5  ounces  of  boiled 
milk,  half  a  lemon  or  2  ounces  of  white  wine,  5  ounces  of  boiling 
water,  and  the  fine  peelings  of  half  a  lemon.  Pour  the  boiling 
water  over  the  peeling  and  the  sugar,  let  this  cool  off,  and  then 
add  to  it  the  milk  and  the  lemon-juice  or  the  wine,  and  strain  the 
mixture  after  ten  minutes. 

General  Medicinal. — The  antipyretic  medicinal  substances  at  cur 
disposal  I  will  name  in  the  order  of  their  seeming  efficacy  to 
reduce  the  temperature,  at  the  same  time  doing  the  least  harm  to 
the  patient : 

Lactophenin,      5  to  10  grains,  I  to  3  times  daily. 

Phenacetine, 3  "     5       "  '  "   .1     "         " 

Antifebrine, 3  "     S       "  i  "  3     "         " 

Antipyrine, 10  "   15       "  I  "  3     '•         " 

In  the  administration  of  any  of  these  four  substances  just  men- 
tioned, it  should  be  remembered  that  they  should  riot  be  given  as 
a  means  of  lowering  the  temperature,  but  rather  to  prevent  the 
temperature  from  rising.  I  found  Daremberg's  method '  in  this 
matter  a  good  precept  to  follow.  If  the  fever  commences  at  two 
o'clock  and  declines  toward  seven  in  the  evening,  and  by  five  o'clock 
it  has  not  risen  over  100°  F.,  Daremberg  gives  about  ten  grains  of 
antipyriiie  at  half  past  three  o'clock  in  the  afternoon  of  the  following 
day.  If  the  temperature  at  three  o'clock  has  already  attained  100° 
F.,  he  gives  the  following  day  ten  grains  of  antipyrine  at  noon  and 
the  same  dose  at  three  o'clock.  If  the  temperature  at  three  o'clock 
is  102°,  he  increases  the  two  doses  to  fifteen  grains  each.  As 
above  mentioned,  I  prefer  to  give  the  lactophenin  or  phenacetine  in 
corresponding  doses  in  place  of  the  antipyrine.  If  any  of  these  rem- 
edies ca'ise  too  much  digestive  disturbance,  they  should  be 
administered  per  rectum.     Quinine  in  large  doses  is  of  little  avail 

1  Daremberg,  "  Traitement  de  la  Piitisie  Pubiionaire,"  vol.  11. 


General 
mt'diciiial 
treatment 
of  fever. 


m 


362 


r'JLMONARY   TUHERCULOSIS. 


m  tflu^ 


4'li 


la 
f'.'' 

It'i  : 


in  the  chronic  fever  of  uibercnlosis.  But  in  some  cases  the  small 
doses — for  example,  two  grains,  several  times  repeated  during  the 
day — act  quite  favorably.  Quinine  in  larger  doses  seems  to  be  of 
more  value  in  the  acute  exasperations,  characterized  by  high  tem- 
perature and  the  suddenness  of  the  onset. 
Bacterio-         Bdihrio-inctiicinal. — One  of  the    most  surprising  thines  to  me 

medicinal  ,       ,     ,  r     i  i  to  to 

treatment;  wliich  I  noticed  in  my  studies  of  the  sanatorium  treatment,  espe- 

antistre|i-  ' 

tdcoccic      cially  in  institutions  situated  in  higher  altitm!       was  the  almost 

serum.  ^  " 

total  cessation  of  the  fever  of  many  of  the  lu  ly  arrived  con- 
sumptives after  a  few  days,  without  the  administration  of  any 
antipyretic  whatsoever.  The  only  explanation  to  me  was  the 
almost  total  absence  of  pathogenic  nn'crobes,  especially  the  strep- 
tococci, in  these  higher  altitudes,  and  consequently  a  cessation  of 
the  association  of  microbes.  This  conclusion  led  me  to  my  exjter- 
iments  with  Marmoreck's  antistreptococcic  serum.'  I  wrote  to 
the  Pasteur  Institute,  and  received  my  first  lot  of  serum  in  June, 
1896.  Through  the  courtesy  of  my  distinguished  teacher.  Pro- 
fessor Biggs,  I  was  allowed  to  test  the  antistreptococcic  action  in 
the  New  York  City  Laboratory  by  a  series  of  experiments  on  ani- 
mals. I  was  fortunate  enough  to  procure  a  virulent  streptococcic 
culture  for  that  purpose.  These  experiments  proved  to  me  that 
Marmoreck's  claims  for  his  serum  in  streptococcic  infection  had  a 
good  deal  of  justification.  Being  convinced  of  the  absolute  harm- 
lessness  of  the  preparation,  I  began  treating  tuberculous  patients 
with  fever  of  evident  septic  type  where  the  bacteriological  exami- 
nation had  revealed  the  presence  of  an  association  of  the  tubercle 
bacilli  with  the  streptococci.  The  injections  were  made  under 
strictest  antiseptic  precaution,  rendering  surgically  clean  the  por- 
tion of  the  skin  selected  for  the  penetration  of  the  needle,  and 
afterward  carefully  covering  the  wound  made  by  the  large,  pre- 
viously sterilized  serum-needle  with  iodoform  collodion.  I  injected 
mainly  in  the  anterior  portion  of  the  tiiigh  or  arm,  and  always 
slowly,  into  the  deep  cellular  or  muscular  structure  (some  patients 
being  very  thin,  this  was,  of  course,  absolutely  necessary).  There 
never  was  any  local  reaction. 

I  will  briefly  summarize  the  results  I  obtained  at  that  time  and 
in  the  subsequent  clinical  experience  I   have  had  with  this  serum. 


'  Marmoreck,   "  Le  Streptocoque  fX  le   Serum   Antistreplococcique,"  "  Annalis  de 
rinstitiit  Pasteur,"  July,  1895. 


1^ 


SYMPTOMATIC   TREATMENT   OF    PULMONARY   TUJIERCULOSIS. 


J63 


The  action  of  the  serum  was  not  always  uniform.  With  patients 
whose  temperature  rose  above  \o2\{.°  V.  for  several  clays  I  did  not 
obtain  any  results.  When,  however,  there  was  a  temperature  of 
only  101  y'>'^  F.  or  a  trifle  over,  with  streptococci  in  the  si)utum,  a 
first  injection  of  10  c.c.  reduced  the  tenijierature  from  1°  to  i  ^°, 
A  second  of  10  c.c.  broujjht  it  down  to  nearly  normal.  A  third, 
fourth,  fifth,  and  si.xth  of  5  c.c.  each,  given  first  every  twenty-four 
hours,  then  at  longer  intervals,  helped  to  maintain  the  normal,  or 
nearly  normal,  temperature,  and  a  general  better  feeling  was 
experienced  by  the  patient. 

Dr.  I'.iiward  J.  Bermingham,  who  used  some  of  the  same  serum, 
which  was  sent  to  me  at  various  times  from  Paris,  kindly  reported 
to  me  four  cases.  All  were  typical  cases  of  mi.xed  infection,  .vith 
streptococci  as  the  main  companion  of  the  tubercle  bacilli.  In  case 
I,  10  c.c.  of  Marmoreck's  serum  reduced  the  temperature  from 
I03j<^  to  ioij/°;  this  had  to  be  repeated  three  times  at  intervals  of 
three  weeks.  Case  2  :  the  temperature  rose  daih'  to  103°  ;  after  one 
injection  of  10  c.c.  of  Marmoreck's  serum  the  temperature  did  not 
go  above  101°  daily  for  four  months.  The  disease  then  progressed 
rapidly  and  the  patient  died  in  three  weeks.  Case  3:  the  tempera- 
ture rose  daily  to  103°  or  105°;  injections  of  10  c.c.  and  15  c.c.  of 
the  serum  were  given  without  effect;  20  c.c.  brought  down  the 
temperature  to  102°,  where  it  remained  for  six  months,  when  patient 
left  the  city.  Case  4:  the  temperature  rose  daily  to  103°  ;  one  injec- 
tion of  10  c.c.  brought  the  temperature  down  to  99 'i°,  where  it 
remained  for  six  months  ;  it  rose  again  to  its  former  height  and  a 
new  injection  reduced  it  to  100°  and  has  not  risen  since — a  period 
of  seven  months. 

Stubbert,  who  experimented  exten.sively  at  the  Liberty  Sanato- 
rium with  Marmoreck's  antistreptococcic  serum,  reports  10  cases 
in  the  "St.  Louis  Medical  Gazette  "of  December,  1898.  Of  these, 
6  improved  and  streptococci  were  no  longer  found  after  the  injec- 
tions;  2  improved,  but  the  streptococci  returned,  and  in  2  cases  the 
antistreptococcic  injections  had  no  effect  whatsoever,  though  in  I 
three  and  in  the  other  eight  injections  of  10  c.c.  were  given. 

Dr.  Weaver,  of  Chicago,  reported  .still  better  results.'  Among 
other  cases  he  cites  one,  in  the  "  Journal  of  the  American  Medical 
Association  "  of  September  5,  1896,  with  a  temperature  of  105°  F., 


m 

St 

w 


!■   < 


if 


'  Wenver,  \V.  II.,  "  -Vntistreptococcic  Serum  in  the  Treatment  of  Consumption." 

■♦  ■ 


I 


I  ii 


li    ,f! ' 


1!         '. 


Chills. 


Exticme 
state  or 
weakness. 


Dyspiicca. 


Enipliy- 
senia. 


264 


PULMONAKY  TUBEKCULOSI.S. 


which  he  broujijht  down  to  nearly  normal  with  a  .single  dose  and 
maintained  it  there  by  repeating  the  injection  every  .second  day. 
However,  I  think  it  will  require  much  more  experimentation  to  fix 
the  real  value  of  this  serum.  Its  action  seems  to  depend  not  only 
upon  the  make  of  serum  u.sed,'  but  also  upon  the  variety  of  strep- 
tococci' in  the  system  and  the  de<jree  of  virulence  of  the  toxines 
produced  by  them.  The  earlier  the  injections  are  made,  the  better 
seem  the  results.  I  should  encourage  its  use  in  pulmonary  tuber- 
culosis wiienever  there  is  a  mixeil  infection,  and  when,  after  a  short 
trial,  absolute  rest,  fresh  air,  and  the  usual  antipyretics,  including 
the  judicious  application  of  hydrotherapeutic  means,  have  failed. 

Chills,  if  not  of  a  malarial  type,  which  a[)pear  in  some  patients 
at  regular  intervals,  should  be  anticipated  by  the  patient  remaining 
in  bed  and  taking  a  hot  lemonade,  etc.  In  summer  the  patient 
should  be  placed  out-doors  during  his  attacks,  in  a  sunny,  windless 
spot.'  If  the  nature  of  the  chills  suggests  the  administration  of 
quinine  it  should  be  given  per  rectum,  so  as  not  to  disturb  the 
digestive  function. 

Extreme  states  of  weakness  mu.st  be  treated  by  careful  stimula- 
tion with  either  champagne,  wine,  whiskey,  milk-punches,  or  kou- 
miss ;  and,  if  this  condition  becomes  chronic,  digitalis,  strophanthus, 
and  caffeine  are  well  indicated.  General  massage  has  at  times  also 
rendered  me  excellent  services  in  such  cases,  combining  with  it  a 
judicious  dieting,  thus  imitating,  in  a  measure,  the  mast  cure  of 
Weir  Mitchell.  Of  course,  all  patients  suffering  from  such  attacks 
should  be  enjoined  to  avoid  all  mental  and  physical  exertions  of 
whatever  nature. 

For  acute  attacks  of  intense  dyspnoea,  besides  a  hypodermic  in- 
jection of  morphine,  the  inhalation  of  oxygen,  or  Walton's  Oxygen 
Compound  (oxygen,  2  parts;  nitrous  monoxide,  i  part;  ozone,  i 
per  cent.),  seems  still  the  best  remedy,  and  every  well-equipped 
sanatorium  or  special  hospital  for  consumptives  should  have  a 
supply  of  oxygen  cylinders  on  hand. 

For  chronic  forms  of  emphysema  and  other  moderate  but  fre- 
quent dyspnoeic  conditions  I    have  found    the  pneumatic  cabinet 


flh 


'  Merieux    (Lyons)    uiitl    Niemann    (Herlin),    "  (jber    Antistreptocokken-Seruni," 
"  Berliner  klin.  Woclienschrift,"  No.  49,  Dec.  7,  1896. 

^  Belfanti  und  Carbone,  "  ("entralhlalt  fiir  Cliirur^'ie,"  Dec.  31,  1S97. 
'  UeUweiler,  "  Die  liehandlung  der  Lungenschwindsucht,"  lierlin,  18S4. 


SYMPTOMATIC   TREATMENT   OF    I'Ur.MONARV   TUBERCULOSIS.     265 

most  valuable  by  letting  the  patient  exhale  in  the  rarefied  atmos- 
phere. To  this  end  the  patient  should  be  made  to  inhale  the  out- 
side air,  but  exhale  into  the  rarefied  atniosj)here  of  the  cabinet. 
With  a  little  practice  the  patient  will  soon  learn  to  alternate  the 
respiratory  movements  and  soon  derive  real  comfort  from  his 
sojourn  in  the  cabinet.  The  modus  operandi  of  this  inhalinjj  from 
without  and  exhaling  into  the  cabinet  is  as  follows:  The  patient 
holds  the  nose-mask  in  place  with  his  hand  ;  he  takes  his  first  inspi- 
ration while  the  physician  begins  to  manipulate  the  lever.  Dur- 
ing the  first  expiration  the  patient  removes  the  nose-mask.  The 
operator,  while  continuing  with  one  hand  to  manipulate  the  lever, 
places  the  palm  of  his  other  hand  tightly  over  the  funnel  of  the  faucet 
during  the  patient's  expiratory  movement,  and  thus  there  is  an 
almost  perfect  occlusion,  and  little  if  any  outside  air  can  enter  the 
cabinet.  With  a  little  practice  these  manipulations  enable  the 
patient  to  breathe  with  ease  and  comfort,  and  gradually  he  loses 
his  distressing  symptom  to  a  considerable  degree.  At  first,  expira- 
tion through  the  mouth  may  be  permitted,  so  as  to  give  the  patient 
rapid  relief  with  the  least  possible  exertion. 

Respiratory  exercises  are  also  of  great  value  in  emphysema  of 
the  lungs.  They  must,  however,  be  differently  executed  from  those 
I  have  recommended  as  prophylactic  and  curative  measures  in 
simple  pulmonary  tuberculosis.  There  should  be  more  abdominal 
breathing;  instead  of  the  inspiratory  the  expiratory  act  should  be 
prolonged,  and  particular  attention  should  be  paid  to  the  second 
expiratory  effort.  During  the  inspiration  a  considerable  pressure 
with  the  palms  of  the  hands  should  be  exerted  over  the  chest,  and 
holding  the  breath  after  the  inspiration  should  be  omitted.  Of 
course,  all  such  patients  must  also  be  especially  careful  regarding 
overexertion.  Walks  taken  with  jmlgment  and  care  on  gradated 
paths  of  various  inclinations  are,  however,  to  be  recommended. 
Too  long  and  animated  conversation  should  be  avoided.  The  diet 
of  these  patients  should  be  superintended  with  particular  care,  and 
all  such  food  as  beans,  peas,  cabbage,  etc.,  which  tends  to  distend 
the  intestines  and  push  up  the  diaphragm,  should  be  strictly  for- 
bidden. With  emphysematous  patients  the  so-called  suralinienta- 
tion,  or  overfeeding,  should  only  be  carried  on  gradually,  since,  as 
a  rule,  they  feel  uncomfortable  when  they  gain  flesh  and  adipose 
tissue  too  rapidly.  Too  voluminous  meals  are  especially  contra- 
indicated.     They  often  cause  veritable  distress  to  the  patient.     The 


i 

i 


ii 


4   !■'- 


ill 


:  it 


•<  I   :    'J 


m' 


i 


Insomnia. 


266 


PULMONARY    TUIiEKCULOSIS. 


proper  way  of  feeding  tliis  cla::.s  of  pulmonary  invalids  is  in  small 
but  more  frequent  meals,  avoiding  taking  too  much  liquid. 

Insomnia  in  tuberculous  patients  is  an  important  symptom,  and 
when  confronted  with  it  one  should  not  rashly  resort  to  the  hyp- 
notics of  the  pharmacopoeia.  In  phthisical  patients  insomnia  may  be 
due  to  irritating  cough,  to  pyrexia,  to  digestive  trouble,  or  it  may 
be  a  purely  nervous  manifestation.  The  therapeutics  of  fever  and 
cough  have  been  sufficiently  dealt  with  in  the  preceding  pages, 
and,  as  a  dietetic  means  of  preventing  insomnia,  I  only  desire  to 
suggest  that  the  patient's  last  meal  before  retiring  should  be  light 
and  very  digestible.  Tea  and  coffee  should  be  strictly  forbidden. 
As  a  sleep-inducing  dish  before  retiring,  buttermilk  is  most  highly  to 
be  recommended  ;  kephir  and  koumiss  may  take  its  place.  The  nerv- 
ous insomnia  of  phth'  'cal  patients  is  less  frequent  in  sanatoria  than 
anywhere  else,  for  there  the  open-air  treatment  is  more  systematic- 
ally carried  out.  Nothing  is  more  conducive  to  sleep  than  remain- 
ing out-of-doors.  If  the  patient  is  able  to  add  a  moderate  amount 
of  physical  exercise  to  his  rest  cure,  he  will  be  almost  certain  of  a 
good  night's  rest.  Of  course,  regularity  in  his  hours  of  retiring 
and  rising  will  be  essential.  Absolute  quiet  should,  as  much  as 
possible,  be  assured  within  and  in  the  vicinity  of  the  consumptive's 
bedroom.  Tlie  bed  should  be  comfortable,  not  too  soft,  not  too 
warm,  and,  of  course,  tlie  room  well  ventilated.  For  the  average 
patient  the  temperature  of  the  bedroom  in  winter  should  be  about 
60°  F.  Whether  to  sleep  on  his  right  or  left  side,  or  on  his 
back,  is  a  matter  of  choice  and  habit.  The  only  thing  which  I  rec- 
ommend my  patients  in  this  respect  is  to  accustom  themselves  to 
sleep  with  as  low  a  head-rest  as  possible.  Feather-beds  as  covers 
should  be  banished  from  the  bedroom  as  unsanitary. 

As  hydrotherapeutic  means  to  induce  sleep  we  must  again  men- 
tion the  wet-pack  with  or  without  the  shoulder-pieces,  as  described 
on  page  254.  Bathing  the  face  with  cool  water  or  lightly  spong- 
ing off  the  whole  body  is  sleep-inducing.  Also  the  vigorous 
friction  of  the  feet  with  a  rough  towel  soaked  in  cold  water,  or  the 
"  effleurage," — that  is  to  say,  gentle  strokes  with  the  palm  of  the 
hand  from  the  neck  downward  and  over  the  spinal  column, — may 
produce  the  desired  effect.  General  massage  should  only  be 
applied  early  in  the  morning  or  during  the  day;  the  same  rule 
should  hold  good  with  the  light  gynmastics,  which  may  at  times 
be  permitted   in  early  cases.     .^11   these   more  or  less  energetic 


small 


SYMPTOMATIC    TREATMENT   OF    PULMONARY    TUBERCULOSIS.     267 

exercises  are  just  as  much  conducive  to  sleep,  aiul  in  fact  more  so, 
when  done  in  the  morning  or  in  the  afternoon  than  when  done  in 
the  evening;  thus,  the  exciting  effect  of  thi  exercises  will  have 
passed  away  by  bed-time,  and  only  tlie  desired  feeling  of  fatigue 
needed  for  sleep  remains. 

Rose,'  in  the  "  Zeitschrift  fiir  Krankenpflege "  of  July,  1898, 
recommends,  as  a  physical  means  of  producing  sleep,  energetic  and 
frequently  repeated  opening  and  closing  of  the  eyelids ;  but  this 
seems  to  be  effective  only  in  the  very  mildest  cases  of  insonmia. 
In  the  following  number  of  the  same  journal,  Huxbaum  -  recom- 
mends auto-suggestion  in  insomnia  with  .^U  patients  inclined  to 
neura.sthenia — in  other  words,  he  tells  the  patient  not  to  fear 
insonmia,  but  to  go  to  bed  with  the  firm  determination  to  sleep. 

The  medicinal  hypnotics,  which  must  be  resorted  to  in  extreme 
cases,  are  morphine  and  chloral.  Morphine  injected  hypoderm- 
ically,  and  chloral  by  rectum,  in  the  smallest  possible  doses,  will 
prevent  digestive  disturbances  apt  to  arise  from  the  administration 
of  these  drugs  by  the  mouth.  While  I  desire  to  repeat  that  sleep- 
producing  drugs  should  only  be  administered  in  pulmonary  tuber- 
culosis after  all  physical  means,  single  or  combined,  have  failed,  I 
would  only  apply  this  rule  to  cases  where  a  cure  or  decided 
improvement  may  be  looked  for  with  reasonable  certainty. 
Phthisical  patients  in  the  last  stages  of  the  disease,  suffering  froni 
insomnia  or  pain,  should  be  made  comfortable  even  at  the  price  of 
making  them  depend,  toward  the  end  of  their  lives,  upon  the 
administration  of  larger  doses  of  morphine  than  would  be  advis- 
able under  ordinary  circumstances. 


'  Rose,  Arthur,  "  Cher  nichtmedikameiitose  Schlafmittel,"  "Zeitschrift  fiir  Kran- 
kenpflege," vol.  x.\,  No.  7. 

-  Huxl).'nim  15.,  "  Die  Kninl<enptlege  der  Schlaflosigkeit." 


m 


1:1 
if  I 


1  4 


!'.<',    • 


CHAl'iER    XVJII. 


1.  ' 


Hygiene 
aiKlmeili- 
cal  treat- 
ment in 
laryngeal 
tubercu- 
losis. 


LARYNGEAL    TUBERCULOSIS   AND   INTERCURRENT 

DISEASES. 

Laryngeal  tuberculosis  must  be  treated  locally  and  generally. 
The  vocal  organs  should  be  given  absolute  rest,  and  the  patient 
should  avoid  all  exciting  occupations  which  will  make  him  talk 
in  spite  of  liis  best  resolutions,  and,  of  course,  he  should  avoid 
strong  winds,  heavy  fogs,  sudden  temperature  changes,  and  all 
places  where  dust  is  raised  or  irritating  odors  fill  the  air  and  cause 
coughing  spells.  For  such  patients  the  selection  of  a  warm,  moist 
climate  is  recommendable  (warm  sea-coasts),  for  they  really  suffer  in 
cold  and  dry  regions.  As  a  rule,  higher  altitudes  are  less  suitable 
for  them.  The  throat  should  be  protected  so  as  to  keep  that 
portion  moderscely  warm.  Schmidt^  insists  that  the  covering 
around  the  neck  should  always  be  loose. 

The  diet  for  patients  suffering  from  laryngeal  tuberculosis  need 
not  differ  materially  from  that  prescribed  for  the  pulmonary 
invalid.  Of  co  irse,  hard  substances,  such  as  bread-crusts  and  dry 
toast,  should  b,-  avoided;  also  much  seasoning,  as  through  their 
ingestion  irr:\ation  and  pain  may  ensue.  For  painful  deglutition, 
weak  codeine  or,  better  yet,  cocaine  application  before  meals  should 
be  made.  A  tablet  of  ^^  of  a  grain  of  hydrochlorate  of  cocaine 
placed  on  the  back  of  the  tongue  is  a  good  way  of  administering  the 
cocaine,  since  the  patient  can  do  this  himself  without  any  danger. 
At  times  hot  inhalation,  with  the  aid  of  a  steam  atomizer,  gives  a 
decided  relief  These  steam  sprays  can  be  medicated  according 
to  the  indication  with  astringent  balsamic,  disinfectant,  or  analgesic 
substances.  A  simple  cold  spray  or  the  external  application  of 
cold  in  form  of  ice-cravats  or  cold-water  compresses  .seems  also 
to  be  beneficial  in  many  cases.  Intratracheal  injections  of  guaiacol, 
menthol,  and  olive  oil,  as  described  on  page  252,  for  persistent 
cough  in  pulmonary  tuberculosis  are  well  adapted  to  the  treatment 
of  this  distressing  symptom  in  laryngeal  tuberculosis. 


'   Schmidt,  M.,  "  I>ie  Krnnkheiieii  der  oberc-n  I.iiftwege,"  Berlin,  lS()4. 

268 


Jl 


>}  I 


LARYNGEAL   TUBERCULOSIS    AND    INTERCURRENT    DISEASES. 


369 


Acrotherapy,  of  course,  must  not  be  neglected  in  such  cases. 
Breathing  e.xercises  should  be  instituted  in  this  disease  as  well  as 
in  pulmonary  tuberculosis.  They  should  be  taken  jutiiciously, 
according  to  the  strength  of  the  patient.  The  milder  the  air  these 
patients  breathe,  the  better  they  will  feel.  My  modification  of  the 
pneumatic-cabinet  treatment,  described  on  page  222,  will  permit 
the  sufferer  from  laryngeal  tuberculosis  to  enjoy  the  benefit  of  this 
valuable  adjuvant  in  aCrotherapeutics  just  as  well  as  the  sufferer 
from  pulmonary  consumption.  ]?y  breathing  through  the  nose 
with  the  aid  of  the  adjustable  mask  instead  of  through  the  mouth- 
tube,  the  air  is  warmed  sufficiently  to  cause  no  irritation  whatso- 
ever, and  the  increased  air-supply  thus  entering  the  respiratory 
organs  has  its  beneficial  effect. 

As  a  urative  measure  the  lactic-acid  application,  varying  in  Lactic 
strength  from  ten  to  seventy-five  per  cent.,  has  thus  far  been  most 
universally  used.  The  most  frequent  way  of  applying  this  acid  is 
directly  upon  the  tubercles  or  ulcerated  surfaces.  It  may,  how- 
ever, be  also  injected  under  the  mucous  membrane.  At  times, 
surgical  interference  is  inevitable,  and  every  large  institution  de- <:;i„.gjca] 
voted  to  the  treatment  of  tuberculous  patients  should  not  be' 
without  its  competent  laryngologist. 

The  removal  of  tuberculous  growth  in  the  larynx  by  means  of 
curettage  seems  to  be  indicated  in  a  certain  number  of  cases. 
Gleitsmann,'  in  his  excellent  report  to  the  Section  on  Laryngology 
and  Rhinology  of  the  Twelfth  International  Medical  Congress  at 
Moscow,  has  promulgated  the  following  indications  and  contra- 
indications of  the  curette  in  laryngeal  tuberculosis: 

Indications  : 

1.  In  cases  of  primary  tuberculous  affections  without  pulmonary 
complications. 

2.  In  cases  with   circumscribed   ulcerations   and   infiltrations   of 


,  im.'asures. 


th( 


lary 


nx. 


3.  In  cases  with  dense,  hard  infiltrations  of  the  arytenoid  region 
of  the  posterior  wall,  also  of  the  ventricular  bands  and  tubercu- 


ous  tumors  o 


f  th 


e  eu\ii 


lottis 


P 


4.  In  the  incipient  stage  of  pulmonary  disease  with  but  little 
fever  and  no  hectic  symptoms. 

5.  In  advanced    pulmonary  disease  with  distressing  dysphagia 


'  Gleitsmann,  I,  \V.,   "Medical  Kecord,"  Dec.  4,  iSqy. 


270 


PULMONARY    TUBERCULOSIS. 


J 


1 , 


'    'X 


I  m 


■t  .¥ 


Obesily  in 

luberciilous 

patients. 


Bronchitis. 


resulting  from  infiltration  of  the  arytenoids,  as  the  quickest  means 
of  giving  relief. 

Contra-indications : 

1.  Advanced  pulmonary  disease  and  hectic. 

2.  Di.sseminated  tuberculosis  of  the  larynx, 

3.  Extensive  infiltrations  producing  severe  stenosis  when  trache- 
otomy is  indicated  or  laryngotomy  can  be  taken  into  considera- 
tion. 

Gleitsmann,  as  well  as  Heryng,  does  not  advise  the  operation  in 
timid,  distrustful  patients  lacking  the  necessary  nerve-power,  and 
both  prefer  to  operate  on  the  patient  in  a  hospital,  where  he  is  under 
absolute  control  and  the  after-treatment  can  be  carried  out  more 
satisfactorily. 

For  the  operation  of  curettage  various  instruments  have  been 
devised,  such  as  Krause's  curettes,  Gougenheim's"  emporte  piece," 
and  Hcryng's  rotary  double  curette.  The  last  one  mentioned  is 
given  the  preference  by  Gleitsmann  because  it  enables  the  operator 
to  remove  a  greater  amount  of  tissue. 

Occasionally  we  meet  a  consumptive  with  more  adipose  tissue 
than  is  good  for  him,  and  in  such  cases  a  fatty  degeneration  of  the 
heart  is  to  be  feared.  Extreme  dyspnoea  and  feeble  heart-action  are 
frequently  the  alarming  symptoms.  To  attempt  to  reduce  their 
fat  by  such  diet  as^prescribed  by  Ebstein,  Harvey,  or  Schweninger 
would  be  dangerous.  The  dieting  must  be  done  much  more  gradu- 
ally, and,  while  it  is  essential  to  relieve  the  heart  from  its  too  fatty 
environment,  such  patients  should  not  lose  more  than  about  two 
pounds  in  the  course  of  one  month.  Moderate  exercise  and  mas- 
sage will  aid  in  replacing  the  adipose  tissue  by  muscular  tissue. 

Bronchitis  must  be  treated  first  prophylactically  by  the  aiiro-  and 
hydro-therapeutic  measures  described  in  the  chapter  on  prophy- 
lactic treatment.  The  inhalation  of  impure,  dusty,  or  irritating 
atmosphere  is  productive  of  bronchitis,  especially  in  consumptives 
whose  point  of  least  resistance  lies  in  the  respirator)'  tract.  An 
unobstructed  nasal  breathing  is  one  of  t!ie  essential  conditions  to 
avoid  bronchial  catarrhs. 

The  use  of  opium  is  certainly  a  valuable  remedy  to  abort  an 
attack  of  bronchitis.  Charbonneau  says  a  full  dose  of  Dover's 
powder  will  frequently  abort  an  attack.  Osier  is  of  the  same 
opinion,  saying  tliat   no   remedj-  can   take   its  place.      h^iigli'^h  ' 

1  "Therapeulic  Hints,"   "Medical  Record, "  Jan.   ; 4,  1899. 


LARYNGEAL   TUIiEKCULOSIS   AND    INTERCUKRENT    DISEASES.      271 


i 

i 


I 


explains  the  tlierapeutic  action  of  opium  in  such  cases  when  given 
in  full  doses  as  follows  :  "  Reactioi'  of  irritability,  congestion,  or 
inflammatory  activity.  Alteration  in  the  character  and  limitation 
of  the  amount  of  the  secretion.  Increase  in  the  general  comfort 
by  relief  of  pain  and  soreness,  and  removal  of  cough  and  inci- 
dental insomnia." 

Counter-irritants,  as  mustard  plasters  or  dry  cupping,  are  good 
local  remedies.  The  inhalation  of  thymol  (one  grain  to  one  ounce 
of  liquid  aibolene)  or  other  antiseptic  or  balsamic  preparations  is 
also  useful.  As  antipyretic  in  an  acute  bronchitis  1  give  quinine 
the  preference. 

If  the  cold-pack — that  is,  cold-water  compresse.: — is  applied,  it 
should  be  done  as  described  on  page  254  for  excessive  hyiJerhi- 
drosis.  Care  should  be  taken  in  removing  the  compresses,  so  as 
not  to  have  the  patient  take  a  new  cold.  It  is  prudent  to  remove 
the  wet-pack  under  the  bed-cover,  and  rub  the  chest  drx-  with  a 
somewhat  rough  towel,  and  follow  this  by  a  vigorous  friction  with 
alcohol.  As  a  cough-mixture  I  use  one  of  those  given  on  page 
252.      Of  course,  any  other  expectorant  may  answer  as  well. 

Pleurisy  may  manifest  itself  in  a  consumptive  as  a  concomitant  Pituris>. 
or  an  intercurrent  disease.  The  acute  forms,  arising  as  a  new 
complication,  must,  of  course,  be  treated  by  rest  in  bed.  If  there 
is  a  large  exudate,  absolute  quiet  before  as  well  as  after  thoracen- 
tesis must  be  'isisted  upon.  If  there  is  but  a  small  amount  of 
liquid  in  the  chest,  dry  cupping  and  mustard  applications  often 
suffice  to  aid  absorption.  Judiciously  directed  respiratory  exercises 
are  also  of  value,  especially  in  the  subacute  and  chronic  form  if 
there  is  no  intense  pain.  To  relieve  the  sometimes  acute  suflfering 
from  intercostal  or  pleuritic  pains,  cold  applications  are  indicated; 
if  they  are  not  well  borne  warm  poultices  may  be  substituted.  Of 
medicinal  substances  opiates  are  at  times  indispensable.  Diuretics, 
such  as  potassium  acetate,  digitalis,  scilhi,',  etc.,  may  be  indicated. 
The  patient's  strength  mu.'t  he  kept  up  by  tonics.  Of  the  value 
of  lateral  douches  and  the  respiratory  exercises,  to  aid  the  absorp- 
tion of  fibrinous  adhesion,  the  residual  of  long-standing  pleuritic 
inflammation,  wc  have  already  spoken  in  the  respective  chapters. 
li  the  pleuritic  exudate  becomes  purulent  (empyema*,  tne  case 
belongs  to  the  domain  of  surgery.  In  the  s[)eedy  and  thorough 
evacuation  of  the  pus  lies  the  mil}'  hope  for  the  recover)-  of  the 
patient. 


m^' 


SI    1. 


If 


F'M 


272 


PULMONARV   TUBERCULOSIS. 


m 


!V 


'      ffi     lb 


Pneumonia.  Pneumonia,  which  in  consumptives  is  usually  of  the  lobular  kind, 
must,  when  arising  in  the  course  of  pulmonary  phthisis,  be  treated 
as  in  any  other  patient.  Rest  in  bed,  careful  antipyretic  medication 
(quinine  or  lukewarm-water  baths),  and,  above  ail,  remedies  to  keep 
up  the  proper  heart-action — digitalis,  alcohol,  etc. — are  essential. 
Professor  A.  Jacobi  counsels  to  give,  from  the  very  onset,  two  drops 
every  four  hours  of  the  fluid  extract  of  digitalis  (Squibb's),  thus 
strengthening  the  heart,  and  by  its  cumulative  effect  putting  the 
heart  in  a  condition  of  defense  at  the  most  critical  stage  of  the  dis- 
ease. Counter-irritation  over  the  whole  of  the  chest  renders  also 
great  service.  The  administration  of  ammonium  carbonate  and 
ammonium  iodide  will  aid  materially  in  the  removal  of  the  in- 
flammatory products  during  the  stage  of  ulceration.  Professor  E.  G. 
Janeway's  method  of  putting  the  pneumonia  patient  on  a  milk 
diet  has  rendered  me  excellent  services  on  various  occasions. 
In  all  cases  the  diet  should  be  in  liquid  form,  not  too  concen- 
trated, and  water  should  be  given  freely.  For  severe  pains,  care- 
fully administered  doses  of  morphia  (hypodermically  over  the  seat 
of  pain)  are  the  best  analgesic. 

Pneumothorax,  during  the  course  of  pulmonary  tuberculosis,  is 
most  frequently  the  result  of  some  sudden  physical  overexertion 
or  traumatism,  such  as  jumping,  running,  rapid  mounting,  loud 
singing,  or  a  sudden  blow  against  the  chest.  Again,  a  violent 
coughing  spell  may  be  the  cause.  It  is  most  important  to  prevent 
such  accidents.  However,  patients  cannot  always  control  their 
coughs,  and  a  pneumothorax  may  occasionally  develop  in  a  con- 
sumptive without  any  apparent  traumatic  origin.  As  in  pneu- 
monia, rest  in  bed  is  es.sential.  Liquid  diet  and  stimulants  of  all 
kinds  are  strongly  indicated.  Leyden,'  of  Berlin,  favors  "  gavage  " 
in  such  cases.  Locally,  the  cold-water  compresses  or  ice-bags 
often  give  relief. 

Pulmonary  gangrene,  which  is  one  of  the  distressing  inter- 
current troubles  that  may  appear  during  the  course  of  pulmonary 
tuberculosis-,  should  be  treated  vigorously  by  tonics  (digitalis, 
caffeine,  alcohol,  etc.).  Jaccoud  recommends  to  give  the  patient 
from  eight  to  ten  grains  of  salicylic  acid  a  day.  As  antiseptic 
inhalation  a  few  teaspoonfuls  of  the  essence  of  turpentine  poured 
into  hot  water  is  to  be  recommended  (Trou-sseau).     Thevaporofa 


Pneunio 
thorax. 


I'liliiKinary 
gangrene. 


■  I.eyden,   "I'ber  rneiiniothorax   tulierculosis," 
schrift,'  1S88. 


]  )eiitsche  niedizinisclie   Woclien- 


LARYNGEAL    TUBERCULOSIS    AND    INTERCURRENT    DISEASES. 


-/  .1 


five  per  cent,  solution  of  carbolic  acid  can  also  be  used  for  the 
same  purpose.  If  there  are  .several  foci,  medicinal  treatment  is  all 
that  is  possible  ;  but  if  the  gangrene  is  circumscribed  and  this  treat- 
ment is  ineffectual,  pneumotomy  and  draina<;e  are  indicated.  The 
part  of  the  lung  involved  has  been  resected  in  some  cases  with 
satisfactory  results. 

Pulmonary  phthisis  complicated  by  diabetes  or  diabetes  com- uiaiiutcs. 
plicated  by  pulmonary  tuberculosis,  of  course,  needs  special  atten- 
tion. Von  Noorden,  who  is  to-day  considered  the  greatest  authority 
on  diabetes,  having  studied  the  subject  perhaps  more  thoroughly 
than  anybody  else,  summarizes  in  the  "Twentieth  Century  Prac- 
tice of  Medicine  " '  by  saying,  "  This  complication  should  not 
cause  any  relaxation  in  the  carrying  out  of  the  suitable  dietetic 
principles  (of  diabetes),  but  rather  demands  greater  strictness  and 
especially  the  greatest  possible  increase  in  the  amount  of  fatty 
food,  with  the  addition  of  considerable  quantities  of  alcohol.  It  is 
advisable  that  the  patients  should  reside  in  places  where  the  climate 
is  mild,  rather  than  in  those  lying  in  high  elevations,  where  the  air 
is  raw,  and  treatment  in  a  sanatorium  is  preferable  to  a  stay  in 
one's  own  home  or  in  a  hotel.  Certain  hydrotherapeutic  measures 
of  a  mild  character  may  be  cautiously  instituted  ;  diabetics  with 
phthisis  are  indinduals  demanding  the  greatest  protection  against 
injurious  influence?.  '  My  only  objection  to  this  excellent  sum- 
mary would  be  that  too  considerable  quantities  of  alcv)hol  are  not 
always  well  oorne  by  these  patieimts.  Whenever  I  give  alcohol,  I 
prefer  to  atnninister  it  at  meal-tiines,  in  the  form  of  light  vt'liite 
wines.  The  main  point,  in  such  cases,  is  to.-trive  to  maintain  the 
strength  of  the  patient  by  a  judicious  suraiinient-jtion  with  ihe 
exclussion  of  sugar,  swet'meaits,  pastry,  preserves,  swxet  j<'llies, 
macarcmi,  peas,  beans,  etc.  A  small  an  «unt  f  bread  and  pota- 
toes should  be  occasionally  allovcd. 

While  pityriasis  versicolor  > tinea  versicolor,  pityriasis  of  I'.ich- I'ityHasis. 
stedt)  can  hardly,  in  the  light  of  nmdem  research,  be  considered 
.symptomatic  of  pulmonar\  phthisi*  it  is,  nevertheless,  met  with 
frequently  enough  in  [phthisical  prr  cnts  to  .nerit  some  consKlera- 
tion  here.  It  is  most  usually  foun^.  >.n  patients  whose  skin  has  not 
received  proper  hygiene.  The  disc.ise  is  due  to  a  vegetable  para- 
site (microsporon  furfur);  the  eruption  is  superficial,  of  yellowish  or 


it' 


Tweiilicili  reiiiiiry  I'laclice,"  vol.  n,  "  I)i.-ilietes  Mcllilus.'' 


I8 


ft 


274 


PULMONARY   TUBERCULOSIS. 


Miliary 

tubLTCll 

losis. 


reddish  color,  and  the  itching  sensation  is  most  intense  when  the 
patient  gets  overheated.  It  is  usnally  located  over  the  sternum  ; 
sometimes,  however,  scattered  over  the  front  of  the  cliest  and  the 
back.  The  edges  of  the  patches  are  rounded  and  somewhat 
elevated. 

The  treatment  consists  in  first  removing  these  patches  by  warm 
baths  with  soap,  preferably  sapo  viridis,  and  then  applying  the 
antiparasitic  remeiiy.  As  an  antiparasitic  the  pure  ichthyol  has 
given  me  much  satisfaction  in  such  cases.  After  having  bathed  the 
affected  parts  as  above  described  I  apply  a  good  coat  of  the  ichthyol 
overnight,  removing  it  in  the  morning  by  the  aid  of  a  weak  solu- 
tion of  bichloride  (i  :  5000  to  i  :  10,000).  Other  applications,  such 
as  salicylic,  carbol,  or  resorcin  salves,  will  also  rarely  fail  to  destroy 
the  parasite.  One  precaution  must  be  insi.sted  upon,  otherwise  the 
trouble  is  sure  ^o recur:  that  is, the  thorough  boiling  and  disinfect- 
ing of  the  patient's  underwear. 

Acute  miliary  tuberculosis  can,  in  the  present  state  of  our  knowl- 
edge, be  treated  only  .symptomatically.  A  remedy  which  I  have 
seen  do  excellent  service,  and  under  which  I  observed  a  few  appar- 
ent recoveries,  is  tannic  acid,  administered  in  large  doses  of  from 
ten  to  fifteen  grains  three  or  four  times  daily. 

At  times,  in  a  patient  suffering  from  pulmonary  tuberculosis, 
even  in  the  earlier  stages,  there  will  be  found  manifestations  of 
joint-tiiber- local  tubcrculosis  in  the  joints,  testicles,  etc.  I  do  not  intend  here 
to  treat  the  subject  from  a  surgical  point  of  view,  but  only  to  indi- 
cate the  newer  methods  of  treatment  applicable  to  the  earlier  stages 
of  joint  tuberculosis.  Bier's  method  of  treatment  by  local  venous 
Iiypera;mia'  I  saw  applied  for  the  first  time  two  years  ago  in  the 
service  of  Dr.  Torek,  at  the  New  York  Post-Graduate  Clinic,  with 
most  satisfactory  results  in  several  cases  of  tuberculosis  of  wrist- 
and  knee-joints.  This  method  consists  of  ligating  the  member 
ab<M-e  the  affected  joint  by  an  elastic  band  of  medium  width.  This 
is  done  several  times  a  day  for  a  period  varying  from  ten  minutes 
to  one  hour  at  the  beginning  and  increasing  the  duration  of  time, 
according  to  the  patient's  susceptibility  and  power  to  endure  the 
pain  and  tickling  sensation  produced  by  the  constricting  band,  up 
to  four  or  six  hours,  or  even  a  whole  night.     The  band  is  applied 


culosis. 


'  Bier.  "  HeiUvirkung  tier  Hyper.lmie,"  "  MUncliener  med.  Wochenschrift,"  1897, 


No. 


I.AKYNGEAL    TUBEKCULOSIS    AND    INTERCUKRKN T    DISEASES.       2/5 

only  tight  eiiouj^h  to  impede  the  venous  circulation,  and  if  the  pain 
becomes  too  intense  the  band  must  be  removed.  It  is  essential  to 
see  that  theconstrictin<r  band  does  not  produce  aniumia.but  hyper- 
aemia  and  swelling.  To  protect  the  skin  it  is  advisable  to  envelop 
the  part  first  by  a  band  of  linen  or  other  soft  material,  and  also  to 
change  the  place  for  ligation  at  successive  applications.  The  cura- 
tive principle  of  this  metiiod  seems  to  lie  in  tlie  fact  that  the  locally 
increased  carbonic-acid  gas,  and,  perhaps,  also  an  increased  phago- 
cytosis, both  attack  the  micro-organisms.  Dr.  Torek  also  had  a 
case  of  advanced  tuberculous  disease  of  the  testicle  treated  by  the 
same  method,  with  gratifying  results.  Of  course,  any  tuberculous 
joint  must,  in  addition  to  this  treatment,  be  given  as  much  rest  as 
possible.  I  have  had  myself  occasion  to  treat  a  few  cases  of  early 
tuberculous  joint-diseases  in  this  way ;  but  I  have  alternated  the 
seances  of  ligation  with  local  hot-air  application  by  the  aid  of  Bctz's 
hot-air  apparatus.  The  relief  which  is  given  to  a  painful  tubercu- 
lous joint  by  Bier's  application  of  the  elastic  band  is  almost  instan- 
taneous; in  all  other  joint-affections  the  cessation  of  pain  after  this 
treatment  is  much  slower,  if  it  is  at  all  effective.  This  has  led 
some  observers  to  make  the  statement  that  the  rapid  cessation  of 
pain  in  a  joint  is  a  pathognomonic  sign  of  tuberculosis. 

The  idea  of  treating  tuberculosis  of  the  joint  by  hot  air  origi- 
nated with  Professor  Verneuil,  of  Paris,  in  1890.  The  hot  air  is  to 
be  applied  to  the  affected  member  with  the  usual  precautions. 
Two  layers  of  Turkish  toweling  should  always  be  wrapped  some- 
what loosely  around  the  arm  or  leg  to  be  treated,  and  the  temper- 
ature should  not  be  higher  than  about  275°  F.  The  hot-air  seance 
can  be  taken  twice  daily,  alternating  with  the  Bier  application, 
but  the  former  should  not  last  longer  than  an  hour.  Local  venous 
hyper£2mia,  followed  by  the  hot-air  treatment,  seems  to  be  for  the 
present  our  best  therapeutic  means  of  dealing  with  early  tubercu- 
lous affection  of  the  upper  or  lower  extremities.  If  the  joint- 
tuberculosis  predominates  over  the  pulmonary  lesion,  and  espe- 
cially in  younger  subjects,  a  sojourn  at  the  sea-coast  should  be 
recommended  in  addition  to  the  local  treatment. 

We  will  finally  mention  Hoffa's  soap  treatment  of  local  tuber- 
culous processes,  a  detailed  description  of  which  appeared  in  the 
"  Miinchener  med.  Wochcnschrift"  of  February  2S,  1899.  Pro- 
fessor A.  Hoffa  uses  the  sapo  kalin.  venalis  transparens  of  linseed- 
oil  and  liq.  kal.  caust.,  crud.  without  alcohol;  t^venty-five  to  forty 


•-.  n 


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.  r' 

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1 

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III 

1 

|| 

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1 

1 

1 

1 

i  I  ill 


Fistula 
ill  alio. 


276 


PULMONARY  TUnERCULOSIS. 


grams  are  rubbed  into  the  skin  of  the  back  from  tlie  neck  to  the 
knees,  with  a  sponge  or  the  pahn  of  the  hand,  two  or  three  times  a 
week,  usually  at  night.  The  soap  is  washed  off  witli  a  sponge  and 
warm  water  after  half  an  hour.  He  has  treated  over  two  hundred 
patients  in  this  way  in  the  last  years  with  the  most  satisfactory 
results.  With  this  general  treatment  Professor  Hoffa  combines  the 
local  treatment  required.  He  reports  most  remarkable  cures  in 
cases  of  multiple  bone  and  joint  tuberculous  processes. 

A  fistula  in  ano  is  not  an  infrequent  occurrence  in  the  later  stage 
of  consumption.  There  is  still  a  variety  of  opinion  as  to  the 
advisability  of  operating.  It  seems  to  me  that  if  conservative 
.  treatment,  such  as  iodoform  injection  and  suppositories,  do  not 
suffice  to  cure  the  fistula,  operative  treatment  should  be  resorted 
to.  Especially  is  an  operation  indicated  if  a  patient  is  fairly 
strong,  but  cannot  walk  with  comfort  on  account  of  the  fistula, 
and  suffers  from  pain  and  discomfort  during  defecation. 

All  other  local  diseases  of  tuberculous  nature  belong  to  the 
domain  of  surgery,  but  all  surgeons  have  learned  that  their  local 
treatment  is  of  little  avail  if  not  combined  with  an  effective  consti- 
tutional treatment  and  building  up  of  the  system.  Good  hygiene, 
appropriate  diet,  and  a  good  condition  of  the  respiratory  organs 
are  most  essential  in  producing  or  maintaining  the  good  result 
which  modern  surgery  may  accomplish  in  the  treatment  of  local 
tuberculous  lesions. 


CHAPTKK  XIX. 

EDUCATIONAL  TREATA^KNT,  PROCINOSIS,  MAUUIAGB,  AND 

CHILDBIRTH.     ' 

The  educational  treatment  of  tuberculous  p.Uients  should,  not 
only  in  the  sanatorium  but  everywhere,  receive  tlic  attention  whic  h 
it  deserves.  To  me  it  has  always  seemed  as  if  a  developing 
phthisis  cli  nges  the  patient's  character  and  disposition  often  to  a 
very  considerible  degree.  Dettweiler  thinks  them  all  imprudent; 
("  ein  leichtsinniges  Volkchen")  a  careless  little  lot  of  people,  he 
calls  them.  I  have  found  many  overcareful,  others  criminally 
careless,  some  sanguine,  some  n-    rose,  some  indifferent,  ai»d  .so  on. 

The  advantage  of  the  institut  ■>  treatment  lies,  as  has  already 
been  stated,  in  the  constant  medica  supervisi.  n  and  the  pos-ibility 
of  keeping  tli>  [)atient  busy  all  day  with  something  which  ha  his 
cure  for  its  definite  object, — at  this  hour  his  I'ueals,  at  that  his 
rest  cure,  at  this  his  respiratory  exerci.ses,  at  that  his  walk,  at 
another  his  douche,  etc.,  etc. 

The  first  matter  in   regard  to  the  education  of  a  pat.  -nt  is,  of 
course,  the  instruction  concerning  the  care     f  the  e.xpector.ition,  of 
which  we  have  spoken  in  detail  in  the  preceding  pages.    Next  in  im- 
portance comes  teaching  him  how  to  avoid  taking  cold.     The  most  frou  tion 
suitable  mode  of  dress  for  consumptives  lias  been  briefly  mentioned  i''kin 
on  pages  235  and  z;^-      The  precautions  to  be  taken  during  respir- 
atory e.xercises  have   also   been   touched    upon.      Consumptives 
should  be  particulai  !y  >    'eful  not  to  face  the  wind  when  taking  these 
e.xercises,  and,  of  cour.-iv,  always  keep  their  mouths  closed.    When 
taking  the  rest  cure  on   reclining-chairs  out  on  the  veranda,  they 
should  avoic!  much  conversing  on  cold  or  windy  days.     The  same 
rule   holds   good    when    out  walking.     In  a    sanatorium   graded 
walks,  such  as  described  on  page  213,  and  the  distribution  of  num- 
bered  benches  will   make  the  method   of  carefully  testing    one's 
strength  from  day  to  day  especially  interesting.     The  consumptive 
should  never  start  out  with  a  determination  that  lie   must  reach 
a  certain  spot.     Overexertion   is  to  be   feared.     The  pulmonary 
invalid    must,    more   than    any   other,   be   careful    not   to   get   in 

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a  perspiration  through  exercise;  'le  should  stop  before  he  gets 
tired,  and  learn  from  day  to  day  at  he  can  do  and  what  he  can 
not  do.  Should  he,  in  spite  of  these  precautions,  begin  to  per- 
spire freely  during  one  of  his  daily  walks,  he  should  not  sit  down 
and  rest  to  cool  off,  bu"-  return  home  at  once, — however,  without 
any  increased  speed, — ask  to  be  rubbed  off,  and  go  to  bed.  A  hot 
lemonade  or  grog  is  administered  and  the  doctor  notified.  If 
the  patient  has  perspired  but  slightly,  he  should  at  least  enter  the 
house  after  his  excursion  and  change  his  under-garments.  In  all 
well-equipped  sanatoria  special  accommodations  for  this  purpose 
are  established.  Carrying  out  rigorously  all  the  instructions  con- 
cerning the  prevention  of  taking  cold  will  save  many  an  inter- 
current bronchitis  or  pleuritis,  or  even  pneumonia.  Patients  often 
take  cold  and  the  cause  escapes  the  most  careful  attention  until  it 
is  discovered  that  they  are  in  the  habit  of  rising  at  night,  in  the 
cool  room,  bathed  in  perspiration,  in  order  to  urinate.  I  always 
insist  that  such  patients  have  a  urinal  placed  near  their  bed,  of 
which  they  can  make  use  without  uncoveri.ig  themselves.  Or, 
again,  the  patient  takes  cold  by  uncovering  himself  during  the  act 
of  expectorating.  As  a  rule,  the  patient  raises  himself  for  that 
purpose  to  a  sitting  posture,  leaning  over,  and  thus  the  cold  air  of 
the  room  strikes  the  whole  thorax.  To  avoid  this  I  tell  my 
patients  to  place  their  pocket-flask  under  their  pillow  at  night.  If 
the  necessity  of  its  use  arises,  the  act  of  expectorating  in  the 
pocket-spittoon  can  then  be  done  with  little  inconvenience  to  the 
patients,  and  without  there  being  a  necessity  of  uncovering  them- 
selves. 

Some  patients  have,  before  entering  the  institution  or  submitting 
themselves  to  treatment,  acquired  bad  habits  which  are  often  the 
cause  of  severe  colds.  One  of  them,  not  common  to  the  fair 
sex  alone,  is  that  of  spending  half  an  hour  or  more  every  morning 
in  a  cool  bedroom,  half  dressed,  to  complete  their  toilet.  Ladies 
will  sometimes  sit  for  hours  scantily  dressed  in  their  cool  bed- 
rooms, just  to  do  a  little  mending.  All  such  habits  must  be 
stopped ;  also  reading  in  bed  at  night.  Patients  should  not  leave 
the  house  before  sunrise,  and  they  should  always  remain  within 
doors  during  the  hour  of  sunset,  especially  in  localities  where 
that  phenomenon  is  accompanied  by  a  rapid  saturation  of  the 
atmosphere  (Riviera,  .Southern  California,  etc.).  Tuberculous 
patients  should  have  at  least  nine  liours'  sleep  in  the  twenty-four. 


EDUCATIONAL  TREATMENT. 


279 


gets 


Extreme  nervousness  is  often  successfully  treated  by  a  gentle 
sponging  off  with  cold  water.  Light  occupations  or  distractions, 
quiet  drives  not  lasting  too  long,  reading,  writing,  unexciting 
games,  and  music  should  be  allowed  the  patient.  Little  writing- 
desks,  which  can  be  attached  to  the  reclining-chair,  such  as  are 
used  in  the  sanatorium  at  Canigou,  in  France  (Fig.  30),  make 
reading  and  writing  especially  convenient  during  the  rest  cure  in 
the  open  air,  and  prevent  the  patient  from  bending  over.  Ladies 
should  not  be  allowed  to  do  fancy  work  which  necessitates  lean- 
ing over.  I  make  it  a  rule  to  control,  in  a  measure,  whenever  it 
is  possible,  what  books  the  patients  read.  Feverish  patients  should 
not  read  exciting  literature.  Quiet  entertainments,  musicales,  and, 
if  possible,  an  open-air  performance ;  instructive  lectures  on  hygiene 
in  general,  and  especially  on  the  hygiene  of  the  tuberculous 
patients  and  the  mode  of  life  of  the  cured  consumptive,  etc., 
should  form  the  pleasant  features  of  sanatorium  life. 

The  patient's  tastes  and  inclinations,  so  long  as  they  do  not  con- 
flict with  his  own  welfare  or  that  of  the  other  inmates  of  the  insti- 
tution, should  be  indulged.  Large  establishments  should  facilitate 
holding  religious  .services  of  the  various  denominations,  so  that 
religiously  inclined  people  should  not  miss  what  may  be  dear  and 
needful  to  them.  All  that  tends  to  make  the  patient  happy  and 
cheerful  should  be  permitted ;  all  that  is  cheerless  and  depressing 
should  be  banished  from  his  surroundings.  Some  pulmonary 
invalids  cannot  bear  the  idea  of  entering  a  sanatorium  ;  they  fear 
the  association,  and  others  fear  the  discipline.  From  my  experi- 
ence as  assistant  physician  at  Falkenstein,  and  from  many  conver- 
sations which  I  have  had  with  the  inmates  of  sanatoria,  who  had 
come  from  all  classes  of  society  and  from  many  different  countries, 
I  learned  that  each  soon  became  so  interested  in  his  own  case  that 
he  forgot  all  trifles,  and  the  attention  bestowed  upon  him  by  the 
physician  and  his  assistants  made  him  feel  that  everything  in  the 
sanatorium  was  done  to  make  him  comfortable  and  to  hasten  his 
restoration  to  health.  This  feeling  predominates  over  all  others, 
and  the  new  arrival  usually  soon  accommodates  himself  to  his 
environments.  Now  as  to  that  much-feared  word,  discipline,  in 
sanatoria  for  consumptives.  The  whole  tiling  consists  in  the  good- 
will and  the  earnest  determination  on  the  part  of  the  patient  to 
follow  the  rules  of  the  house,  which  have  been  created  in  his 
interest,  and  to  obey  the  counsel   and  carry  out  the  prescriptions 


ICMrcnie 
iicvous- 

IIUS-'S. 


Social  life 
and  dis- 
cipline. 


;«|i 


•  t" 


,-ik 


i 


li 


28o 


PULMONARY   TUBERCULOSIS. 


Exainina 
lion  or 
patients. 


of  his  physician  ;  and,  on  the  part  of  the  physician,  a  never-failing 
kindness,  combined  with  an  unmoved  firmness  when  occasion 
demands. 

On  the  arrival  of  the  patient  in  the  sanatorium,  to  which  he 
should  come,  if  possible,  with  a  letter  from  his  family  physician, 
and  never  without  having  previously  been  assured  by  the  physician- 
in-charge  that  there  is  room  for  him,  he  is  told  first  to  rest  from 
his  journey.  The  next  morning  he  will  be  submitted  to  a  thorough 
examination  of  his  physical  condition,  and,  in  taking  down  the  his- 
tory of  the  case,  the  observant  physician  will  learn  something  of 
the  disposition  and  state  of  m'nd  of  his  new  patient,  and  the  educa- 
tional treatment  will  begin  aV  once.  Of  course,  this  must  be  in 
accordance  with  the  degree  of  intelligence  the  newly  arrived  con- 
sumptive possesses.  He  is  made  acquainted  with  the  rules  and 
regulations  of  the  house.  He  is  instructed  to  be  punctual  at  meals, 
and,  above  all,  never  to  fear  to  ask  counsel  or  advice  of  one  of  the 
physicians  always  present. 
Prognosis.  The  question  will  often  arise  whether  a  definite  prognosis  should 
be  given  to  the  friends  or  relatives  of  the  i)atient,  and  whether  or 
not  he  should  be  told  his  true  condition.  There  is  hardly  a  dis- 
ease ir,  the  world  of  which,  except  in  the  advanced  stages,  it  is  more 
difficult  to  give  a  definite  prognosis  than  in  pulmonary  tuberculosis. 
Any  one  who  has  had  a  number  of  tuberculous  patients  under  his 
observation  will  agree  with  me  if  I  say  that  there  are  cases  in 
which,  to  judge  from  a  careful  physical  examination,  the  best  hopes 
of  recovery  should  be  held  out  to  the  patient;  and  still  he  rapidly 
declines  and  sometimes  unexpectedly  dies.  On  the  other  hand, 
not  infrequently  patients  surprise  us.  Their  extensive  pulmonary 
lesions  left  us  not  the  least  hope,  and  we  may  have  told  the  friends 
of  the  apparently  gloomy  aspect  of  the  case ;  and  lo  !  some  years 
later,  one  fine  day,  the  patient  presents  himself  at  our  office,  if  not 
cured  in  the  ad  integrum  sense,  at  least  to  all  outward  appearances 
in  perfect  health. 

Nor  can  our  knowledge  of  bacteriology  aid  us  much  in  this 
respect.  The  presence  of  the  tubercle  bacilli  in  the  sputum  con- 
firms beyond  doubt  the  diagnosis,  but  not  finding  them  at  the  first, 
second,  or  even  the  third  bacteriological  examination  does  not 
exclude  the  possibility  of  a  tuberculous  disease  of  the  lungs.  On 
examining  sputa  from  advanced  cases  one  often  finds  a  relatively 
small  number  of  bacilli  in  the  field  of  the  microscope,  while  the 


SUA 


PKOGNOSIS. 


281 


examination  of  the  expectorated  product  of  a  convalescent  patient, 
ot  one  with  very  limited  pulmonary  lesions,  reveals  sometimes 
enormous  quantities  of  bacilli  (No.  10,  according  to  Gaffky's  scale). 
This  expectoration  may  have  come  from  one  single  cough  in  days 
or  weeks,  and  the  sudden  appearance  of  countless  numbers  of 
bacilli  may  have  been  due  to  the  detachment  of,  perhaps,  a  very 
small  focus  of  encysted  tuberculous  substance.  The  encystment 
of  larger  foci  in  a  stronf^,  fibrinous  shell  may  explain  the  absence 
or  very  small  number  of  bacilli  in  the  sputa  of  apparently  doomed 
patients. 

I  have  found  it  good  policy  to  be  always  most  careful  in  making 
any  positive  declaration  to  the  relatives  or  friends  of  the  patient. 
A  prognosis  in  a  case  of  pulmonary  phthisis  does  not  depend 
only  upon  the  condition  of  the  patient's  lungs,  his  power  of  diges- 
tion and  assimilation,  but  it  depends  also  upon  his  temperament, 
his  social  condition,  and  his  means.  I  believe,  in  many  cases, 
Grancher's  maxim, "  le  proncstic  de  la  phtisie  pulmonaire  commune 
depend  en  efiet  du  malade  autant  et  plus  que  de  la  maladie"  (the 
prognosis  of  ordinary  pulmonary  phthisis  depends  in  reality  as 
much  and  more  on  the  patient  than  on  the  disease),  is  only  too 
true.  So  I  think  the  best  thing  to  do  is  to  tell  the  patient  that 
the  chances  of  his  recovery  depend  upon  his  obedience  in  carrying 
out  the  treatment  prescribed  for  him.  If  he  is  of  a  particularly 
melancholy  disposition  "  suggestion-therapy  "  will,  of  course,  form 
an  important  factor  in  the  management  of  the  case.  This  will  be 
especially  needful  when  there  is  a  consumptive  family  history,  for 
I  have  learned  how  difficult  it  is  to  dissuade  a  patient  from  the  pre- 
conceived idea  that  he  has  to  die  of  consumption  because  some 
one  in  his  family  died  of  it. 

The  physician  of  the  consumptive  must  be  his  friend  and 
teacher  at  the  same  time.  The  physician's  advice  will  and  should 
be  sought  in  many  of  "^he  most  secret  family  matters, — in  all  the 
subjects  of  sexual  relation,  marriage,  childbirth,  nursing  the  infant, 
etc., — and  it  is  the  duty  of  the  true  modern  phthisio-therapeutist  to 
enlighten  his  patient  on  these  vital  issues,  whether  consulted  about 
them  especially  or  not. 

At  times  a  rise  of  temperature  will  be  observed  in  spite  of  the 
patient's  assurance  that  the  physical  and  mental  rest  has  been 
observed.     The  increased  pyretic  state  may  then  find  its  explana- 


Mirriage 

Ifl.ltiollS. 

etc. 


-h 


(■'').■ 


1.1. , 

ill 


m) 


;    ',1 


283 


PULMONARY  TUL  <'RCULOSIS. 


!llfl>l 


1 

,j 

1 

Childbirlh 
and  mirs- 
iiig. 


tion  in  an  overindulgence  in  sexual  pleasures,  which  a  tuberculous 
invalid  should  exercise  only  at  the  rarest  intervals. 

Some  tuberculous  women  suffer,  at  the  time  of  their  monthly 
period,  from  pulmonary  congestion  and  h.-cmoptysis.  To  these, 
absolute  rest,  beginning  three  or  four  days  before  and  lasting 
throughout  the  period,  should  be  the  rule,  Daremberg  recom- 
mends, in  addition,  a  mustard  plaster  over  the  lower  abdomen, 
and  gives  some  bromide  with  digitalis  to  quiet  the  pulmonary 
condition. 

As  a  rule,  the  tuberculous  patient  should  not  marry ;  but  I 
have  no  hesitation  to  give  my  consent  to  marriage  when  the 
patient  has  been  cured,  or,  since  some  authorities  do  not  accept 
this  word  in  the  ad  integrum  sense,  if  he  has  remained  in  good 
health  for  two  successive  years.  He  should,  however,  be  im- 
pressed with  the  importance  of  his  living  a  quiet,  regular  life,  free 
from  excesses  of  any  kind.  There  are  times,  however,  v/hen  we 
must  deviate  from  the  iron  rule  not  to  allow  a  tuberculous  patient 
to  marry.  If  we  are  in  the  pre.sence  of  a  young,  highly  impres- 
sionable woman  in  the  first  stages  of  pulmonary  tuberculosis,  who 
is  engaged  to  be  married,  it  would  be  cruel  and  unwi.se  to  put  a 
stop  to  the  union :  the  con.sequent  sorrow  brought  upon  this 
young  woman  would  simply  mean  hastening  a  fatal  termination 
of  her  disease,  while,  as  a  happily  married  woman,  she  has  a  fair 
chance  of  getting  well.  This  is  one  of  the  few  instances  in 
the  practice  of  medicine  where  it  becomes  the  duty  of  the  physi- 
cian to  tell  the  husband  that,  if  his  wife  becomes  pregnant  before 
her  complete  recovery,  it  means  danger  to  her  and  to  the  child, 
and  the  husband  should  be  instructed  to  that  effect.  When, 
nevertheless,  a  tuberculous  woman  has  become  pregnant,  should 
we  interfere  with  a  view  of  saving  the  woman's  life?  To  judge 
from  what  I  have  seen  in  the  large  maternity  hospitals  of  the  Old 
and  the  New  World,  and  from  my  own  personal  experience,  such 
procedures  are,  in  the  light  of  our  present  knowledge,  no  longer  jus- 
tified. Tarnier,  Hergot,  Gaulard,'  and  others  have,  in  accidental  or 
brought-about  abortions,  seen  the  mother's  tuberculous  disease  take, 
nevertheless,  the  rapid  course  so  frequently  observed  after  an  appar- 
ent improvement  in  ca.ses  which  go  to  full  term.     During  my  visit 


a-' 

i 

M,           ■ 

1 

1 

■!'• 

1 

1 

lit  i 

'  "  Presse  miidicaie,"  Dec.  S,  1894. 


MARRIAGE    AND    CHILDBIRTH. 


283 


to  the  various  sanatoria,  I  inquired  into  the  results  obtained  by 
the  hygienic  and  dietetic  treatment  in  these  institutions  with  preg- 
nant tuberculous  women.  Dettweiler,  Meissen,  Wolff,  Roempler, 
Turban,  and  Trudeau,  had  observed  cases  where  the  patients  did 
remarkably  well  for  years  after,  as  also  did  their  children. 
Sabourin,  Achtermann,  and  Weicker,  on  the  other  hand,  had  only 
observed  an  apparently  much  improved  state  before  the  birth  of 
the  child,  followed  by  a  rapid  decline  after  confinement.  To  sum- 
marize this  important  question  we  would  say:  Prevent  conception 
in  a  tuberculous  woman ;  if  conception  has  taken  place,  institute 
hygienic  and  dietetic  treatment,  preferably  in  a  sanatorium  near 
the  home  of  the  patient.  But,  as  Trudeau  says,  it  is  essential  that 
the  treatment  be  continued  for  a  long  time  afterward ;  and  I  should 
like  to  add  that  a  repetition  of  pregnancy  must  be  prevented. 
Never  bring  about  abortion,  for  it  does  not  save  the  life  of  the 
tuberculous  mother. 

It  goes  without  saying  that  a  tuberculous  mother  should  not 
nurse  her  child.  A  child  whose  father  or  mother  is,  or  has  been, 
phthisical  should  be,  from  its  very  earliest  age,  surrounded  by  the 
best  hygiene.  Especial  care  should  be  given  to  its  nutrition.  A 
healthy  wet-nurse  would,  of  cour.se,  be  the  best  guaranty  for  the 
child's  normal  development.  If  the  procuring  of  a  healthy  foster- 
mother  is  impossible,  sterilized  cow's-milk,  carefully  diluted  with 
boiled  water,  etc.,  must  constitute  the  child's  food. 

All  the  precautionary  measures  that  have  been  fully  described 
in  our  chapter  on  Preventive  Treatment  should,  if  possible,  be 
instituted.  All  offspring  of  tuberculous  parents  should  choose 
out-door  occupations  by  which  to  earn  their  livelihood,  and  live  and 
work  in  places  where  they  are  as  little  as  possible  exposed  to  the 
inhalation  of  dust  and  other  irritating  substances.  The  cured  or 
ameliorated  patient,  upon  his  return  home,  should  lead  a  very 
regular  life.  He  should  avoid  crowded  assemblies  and  violent 
physical  exercises ;  in  short,  use  his  experience  and  training  in  the 
sanatorium  as  a  guide  to  keep  well  or  to  complete  his  cure. 

To  those  who  doubt,  the  physician  should  hold  out  living  exam- 
ples of  cured  tuberculous  patients,  which  are  so  numerous  that  I 
do  not  think  I  exaggerate  when  I  say  that  a  few  can  be  found  among 
the  patients  of  every  general  practitioner.  Pulmonary  tuberculosis 
is,  indeed,  one  of  the  most  curable  of  all  diseases,  but  the  treatment 
requires  more  attention  on  the  part  of  the  physician,  perhaps,  than 


Tiihcrcu- 
loiis  otl- 
spring 
and  cured 
patients. 


'D  , 


if 


iMi 


'H^ 


Duration 
of  cure. 


1   ; 


Training 
of  pliysi- 
cia;i  and 
nurses. 


I 


'If  ■''•' 


f  m 


384 


PULMONARV  TUBERCULOSIS. 


any  other,  for,  as  the  preceding  pages  have  shown,  besides  the  great 
prevailing  symptoms,  many  little  ailments  and  causes  of  new 
disturbances  ari.se. 

It  is  rarely  wise  to  deceive  a  tuberculous  patient  as  to  the  prob- 
able duration  for  his  cure.  Some  will  be  able  to  resume  their 
daily  occupation  within  three  months,  others  not  before  three  years. 
It  will  not  only  depend  upon  the  extent  of  the  lesions  produced  by 
the  tuberculous  process  and  upon  the  manner  in  which  the  system 
responds  to  the  treatment;  but  also  in  a  measure  upon  the  degree 
of  hope  and  confidence  with  which  the  physician  can  inspire  his 
patient.  In  looking  after  the  patient's  condition,  from  the  most 
alarming  symptom  endangering  life  to  the  slightest  cause  of  dis- 
comfort, and  in  the  endeavor  to  remove  or  ameliorate  them  all,  lies 
the  .secret  of  success. 

It  may  not  be  inappropriate,  at  the  close  of  the  chapter  on  Edu- 
cational Treatment,  to  say  a  few  words  about  the  education  of  the 
physician.  Modern  phthisio-therapeutics,  as  carried  out  in  well- 
equipped  sanatoria,  must  be  practically  studied.  The  custom, 
recently  instituted  by  Professor  Curschmann,  of  Leipsic,  and  Pen- 
zoldt,  of  Erlangen,'  of  making  excursions  with  their  students  to 
neighboring  sanatoria  as  a  practical  demonstration  of  their  lectures 
on  phthisio-therapeutics,  seems  to  me  well  worth  imitating.  There 
is  much  to  be  seen  in  such  institutions  which  will  be  of  value  to 
the  young  practitioner.  A  few  years  ago  Weber,  of  London,  esti- 
mated that  there  is  only  room  in  special  institutions  for  about  one 
tuberculous  patient  in  a  thousand.  Since  then  the  sanatoria  have 
multiplied,  but  there  still  remains  a  large  percentage  of  tuberculous 
patients  to  be  treated  by  the  family  physician ;  therefore,  the  more 
thorough  his  training  in  the  management  of  so  universal  and  com- 
plex a  disease  as  pulmonary  tuberculosis,  the  more  will  be  accom- 
plished in  the  line  of  prevention  and  cure. 

Chronic  pulmonary  consumption  is  not  an  ea.sy  disease  to  treat. 
It  requires  not  only  a  thorough  knowledge  of  the  etiology,  path- 
ology, and  therapy,  and  a  familiarity  with  all  the  symptoms  of  the 
disease,  but  also  a  great  deal  of  devotion  and  patience,  combined 
with  great  strength  of  character.  The  peculiar  psychological  state 
of  nearly  all  phthisical  patients,  we  repeat  once  more,  makes  it  neces- 


•  Penzoldt  und  Stintzing,  "  Hancllnich  der  Therapie  der  Erkrankungen  der  Atmungs- 
und  Kreislaufsorgane,"  Jena,  1898. 


TRAINING  OF   PHYSICIANS   AND    NURSES. 


28s 


new 


sary  for  the  true  phthisio-therapeutist,  not  only  to  be  to  his  patient 
a  devoted  physician,  but  also  his  best  and  most  confidential  friend. 
Nurses  who  undertake  to  help  the  physician  in  his  care  of  the 
consumptive  invalid  should  be  physically  strong  and  of  a  cheerful 
disposition,  and  especially  prepared  for  this  kind  of  work.  A 
nurses'  training  school  might  advantageously  be  attached  to  some 
of  the  larger  sanatoria.  There  exists  already  one  at  the  Loomis 
Sanitarium  at  Liberty,  which  does  excellent  work  in  preparing 
young  women  for  the  special  duties  required  as  nurses  to  patients 
afflicted  with  tuberculous  diseases. 


-m'\ 


m 


!  1  ; 


;, 


} 


li 
1^ 


firf- 


■fj 


CHAriKR   XX. 


UT 


in 


m 


TUBERCULIN,  OTHER  CULTURE  PRODUCTS,  SERUMS, 

ETC.,  IN  THE  TREATMENT  OH  PULMONARY 

TUBERCULOSIS. 

We  will  now  say  a  few  words  in  relation  to  culture  products. 
Foremost,  of  course,  .stands  the  tuberculin,  of  which  the  first  men- 
tion to  the  medical  world  was  made  by  Robert  Koch  at  the  Inter- 
national Medical  Congress  in  rSgo.  The  results  obtained  with 
Koch's  first  tuberculin,  when  employed  for  a  curative  purpose,  have 
been  almost  universally  at  least  deeply  disappointing,  if  not  disas- 
trous. Its  diagnostic  value  cannot  be  disputed,  and  in  the  lower 
animals  it  has  given,  as  such,  definite  and  useful  results.  The  wis- 
dom of  its  use  for  diagno.stic  purposes  in  the  human  race  I,  for  one, 
dare  to  question.  Five,  or  even  ten,  milligrams  of  tuberculin  may 
in  nine  hundred  and  ninety-nine  cases  do  nothing  but  reveal  a 
latent  tuberculosis  ;  buf  in  the  thousandth  case  it  may  cause 
an  unexpected  generalization  with  a  fatal  result.  When  one  has 
witnessed  such  a  generalization  his  desire  to  use  tuberculin  for 
diagnostic  purpo.ses  in  the  human  race  is  diminished.  A  drug 
or  any  other  substance  which,  when  introduced  into  the  system, 
is  capable  of  bringing  about  a  sudden  rise  of  temperature,  some- 
times as  much  as  four  degrees  above  the  normal,  and  which, 
tlirough  the  circulation,  will  reach  the  tuberculous  deposits,  if 
such  are  present,  irritating  these  latent  tubercles  into  an  active 
process  of  inflammation,  must  be  considered  a  dangerous  thing. 
Ambler,'  of  Asheville,  in  an  article  upon  the  early  diagnosis  of 
pulmonary  tuberculosis,  asks  whether  any  physician  would  be 
willing  to  risk  the  consequences  of  such  a  method  of  diagnosing 
a  disease;  and,  addressing  physicians  directly,  he  says  :  "  Do  you 
believe  you  would  carry  out  such  a  procedure  in  your  own  person 
under  such  possibilities?  If  you  would  not,  you  have  no  right  to 
use  it  upon  your  patients." 


'Ambler,   "The    Karly  Diagnosiii   of  Pulmonary   Tuberculosis," 
Journal,"  I'eb.  12,  1898. 

286 


N.    V.    Mod. 


TUHEKCULINS    AND   OTIIEK    CULTUKE    rROOUCTS. 


:S7 


If  1  find  myself  in  the  presence  of  a  case  of  suspected  pulmonary 
tuberculosis,  and  repeated  careful  auscultations  of  the  patient's 
chest,  and  a  number  of  bacteriological  examinations,  and  even  an 
examination  by  the  X-rays  cannot  confirm  the  suspicion,  I  institute 
the  educational,  hygienic,  and  dietetic  treatment  for  a  few  months, 
certain  that  it  will  do  an  enfeebled  organism  a  great  deal  of  good. 
It  may  prevent  a  very  latent  tuberculosis  from  ever  developing  or 
fortify  a  predisposed  individual  against  the  invasion  of  the  tubercle 
bacilli. 

In  some  sanatoria  (Adirondacks,  Dr.  Trudeau ;  Davos,  Dr. 
Turban)  and  in  some  special  hospitals  small  doses  of  tuberculin, 
much  smaller  than  formerly  recommended  by  Koch,  are  continu- 
ally used  as  a  curative  means,  and  good  success  reported,  especially 
in  the  early  cases.  But  may  we  not  ascribe  these  good  results  just 
as  much  to  the  hygienic,  dietetic,  and  symptomatic  treatment  so 
rigorously  adhered  to  in  these  institutions,  where  sucii  good  results 
were  obtained  before  tuberculin  was  ever  used  ?  There  are  also 
numerous  general  practitioners,  and  among  them  such  men  as 
VVhittaker,'  of  Cincinnati;  Spengler,-  of  Davos;  Barton,''  of  New 
York,  who  still  believe  in  the  curative  power  of  this  culture- 
product.  But  do  not  these  distinguished  practitioners  also  in 
their  private  practice,  as  well  as  in  hospital  practice,  insist  upon 
the  very  best  hygiene  and  diet  for  their  tuberculous  patients? 

Specialists  in  cutaneous  diseases  have  reported  cases  in  which 
tuberculin  has  favorably  modified  the  growth  of  lupus,  and  others 
where  the  injections  did  not  stop  the  growth. 

What  has  just  been  said  of  Koch's  first  tuberculin  as  a  curative 
agent  we  may  say  of  all  its  modifications.  The  tuberculocidin 
and  its  child,  the  antiphthisin  of  Klebs  ;  the  tuberculinum  purifi- 
catum  of  von  Ruck,  Whitman's  purified  tuberculin,  Hirschfelder's 
o.xytuberculin,  Koch's  new  tuberculin  R  (though  the  latter  has 
already  been  withdrawn  from  the  market  by  its  manufacturers), 
etc. — all,  in  the  hands  of  some  e.xperimenters,  have  produced  satis- 
factory results.  I  do  not  wish  to  speak  of  their  respective  merits, 
but  from   what  I   have  seen,  heard,  and   read,   I   may  summarize 


I     I! 


'  Wliittaker,  "  General  Impressions  from  Six  Years'  L'se  of  tlie  Old  Tuberculin," 
"  Journal  Amer.  Metl.  Assoc,"  Nov.  6,  1897. 

'  .Spengler,  "  Deutsche  med.  Woclienschrlft,"  No.   36,  l8()7. 

^  I!;ulon,  "  The  Scientific  Irealnient  of  I'uberculosis,"  "  Medical  Record,"  Septem- 
ber, 1897. 


388 


PULMONARY   TUBERCULOSIS. 


i 


m^ 


m 


their  reported  curative  effects  by  saying  of  them  collectively: 
Whenever  a  new  culture-product  is  discovered,  and  through 
experiments  on  the  guinea-pigs  is  shown  to  have  a  specific  anti- 
tuberculous  action,  it  is  usually  recommended  with  the  following 
restrictions : 

Not  to  be  applied  in  advanced  cases. 

Not  to  be  applied  in  mixed  infections. 

Not  to  use  it  as  exclusive  remedy,  but  always  in  connection 

with  the  best  of  hygiene  and  the  best  of  diet. 
Not  to  neglect  the  symptomatic  treatment. 

And  the  results  of  the  treatment  read  about  as  follows: 

A  large  percentage  of  incipient  cases  were  cured. 

A  small  percentage  of  advanced  cases  were  benefited. 

A  still  smaller  percentage  remained  indifferent  to  the  treatment. 

A  very  small  percentage  died. 

Cannot  any  one,  private  practitioner  or  sanatorium  physician, 
report  just  as  good  and  even  better  results  whenever  the  hygienic, 
dietetic,  symptomatic,  and  educational  treatment  has  been  carried 
out  conscientiously  without  the  aid  of  any  specific  or  antibacillary 
remedies  ? 

Of  the  serum  of  Maragliano,  Paquin,  and  others,  we  can  only 
say  the  same,  though  I  am  glad  to  acknowledge  that  I  have  not 
yet  seen  any  real  ill  effect  from  their  employment  in  tuberculosis. 
I  cannot  say  this  of  tuberculin. 

Of  Brunei's  "sue  pulmonaire"'  (lung-juice),  we  know  as  yet  too 
little  to  express  an  opinion.  His  claims  are  based  on  Brown- 
Sequard's  theory  of  the  utilization  of  organic  extracts  as  thera- 
peutic agents. 

Lastly,  we  desire  to  allude  to  the  treatment  by  inhalation  of 
"  formalina,"  recently  instituted  by  Professor  Cervello,  of  Palermo. 
P'ormalina  is  said  to  be  a  powerful  antiseptic  gas,  expensive  and 
difficult  to  obtain.  No  opportunity  has  been  offered  yet  to  try  the 
remedy  in  this  country;  but  the  good  results  reported  by  Pro- 
fessor Cervello  justify  mentioning  this  new  therapeutical  agent  in 
phthisis. 

Whether  or  not  other  bacterio-thera:K;i'f)  its  will  offer  us  that 
long-hoped-for  remedy  which  will  cure  tubciculosis  with  a  degree 


'  Urunet,  F.,  "  Lo  Sue  I'ulmonaire  (Effets  physlologioufis  et  thirapeiuiques),"  Bor- 
deaux, Imprimerie  Y.  (adorct. 


u 


TUllEKCULINS    AND   OTIIICK   CULTUKE    I'KOUUCTS. 


289 


of  certainty,  so  that  the  name  spe:-ific  may  be  justified,  I  am  not 
prepared  to  say.  But  it  seems  to  me  difficult  to  believe  that  we 
will  ever  have  a  serum  or  tuberculin  which,  in  a  few  weeks,  even 
with  numerous  injections,  will  be  able  to  produce  enoufjh  fibrous 
connective  tissue  to  strangle  countless  tubercles  which  it  took 
years  to  form,  or  to  create  enough  phagocytic  blood-corpuscles 
to  swallow  myriads  of  bacilli.  v^Ve  may  employ  serotherapy  in 
acute  exasperation,  due  to  an  association  of  microbes,  but  to  heal 
a  tuberculous  lesion  we  must  produce  new  tissue,  new  and  better 
blood.  How  this  may  best  be  done  I  have  endeavored  to  outline 
in  the  preceding  pages.  Even  should  the  future  give  us  a  bacte- 
ricidal substance  strong  enough  to  annihilate,  without  hurting  the 
patient,  all  the  tubercle  bacilli  which  may  have  invaded  him,  to 
build  up  his  m-ich  weakened  system,  to  protect  him  from  inter- 
current diseases  and  possible  relapses,  the  hygienic  and  dietetic 
treatment  in  sanatoria  or  under  good  medical  supervision,  and  in  a 
fairly  good  climate,  where  the  extremes  of  temperature  are  not  too 
pronounced  and  the  air  free  from  pathogenic  organisms  or  irritat- 
ing substances,  will  still  remain  the  only  rational  method. 


I    I 


H 

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19 


mW 

M 


m 


CHAPTER   XXI. 
CONSUMPTIVRS  IN  HEALTH  RESORTS,  SPORTS,  ETC. 

We  have  outlined  in  the  preceding  chapters  what  constitutes  a 
careful  treatment  of  tuberculous  patients  in  a  closed  establishment 
under  the  constant  supervision  of  the  medical  attendant.  Can  the 
same  conditions  be  realized  in  an  open  health  resort  ?  In  some 
instances,  yes ;  in  the  majority  of  cases,  however,  I  have  no  hesi- 
tation to  answer  emphatically,  "  no." 

In  our  American  resorts,  such  as  Southern  California,  Florida, 
etc.,  the  tuberculous  invalid  is  perhaps  less  bent  on  pleasure  than 
the  consumptive  visitor  to  the  European  health  resorts,  but  he  is 
more  inclined  to  business.  How  often  (in  Southern  California) 
have  I  observed  the  newly  arrived  guest,  after  a  few  weeks'  sojourn, 
plunge  himself  into  business,  especially  exciting  real  estate  and 
other  speculations ! 

In  health  resorts,  no  matter  how  beautiful  the  climate,  if  the 
patients  are  at  liberty  to  do  as  they  please,  I  affirm  that  all  attempts 
at  an  effective  cure  are  an  illusion.  In  the  great  health  resorts  of 
the  Riviera  I  have  seen  any  number  of  consumptives  promenading 
in  the  close,  dusty  air  of  the  casinos  gambling,  smoking,  expecto- 
rating everywhere.  At  the  fad/e  dlibte  they  usually  eat  little,  or 
that  which  is  not  good  for  them.  Now  and  then  they  consult  a  phy- 
sician, whose  directions  they  carry  out  only  so  far  as  does  not 
incommode  them.  Sometimes  they  do  not  even  go  to  see  a  doctor, 
but  have  some  of  the  countless  prescriptions  filled  of  which  they 
have  brought  a  supply  from  home.  After  a  while,  feeling  no 
better,  they  leave,  disgusted  with  the  climate  that  has  done  them 
no  good,  and  blame  the  physician  who  sent  them  there. 

In  the  next  resort  the  same  thing  is  repeated,  or  they  go  to  the 
mountains  for  a  change.  In  some  cases,  by  the  change  of  climate 
and  out-door  life,  they  really  get  better.  They  will  then  feel  them- 
selves privileged  to  make  long  excursions,  climb  mountains,  or  (in 
winter)  skate,  ride  toboggans,  or  race  on  snowshoes.  How  danger- 
ous such  sports  are  for  the  phthisical  patient,  even  if  on  the  road 
to  recovery,  is  well  known. 

290 


.^dBWWi 


CONSUMPTIVES    IN    HEALTH    RESORTS,   SPORTS,    ETC. 


291 


Especially  bad  for  pulmonary  invalids  have  alw  ays  seemed  to 
me  the  sports  which  demand  frequent  stooping  down,  such  as 
croquet,  bowling,  etc.  Bicycling  is  now  quite  frequently  indulged 
in  in  health  resorts  by  tuberculous  patients  in  the  earlier  stages, 
and  especially  by  those  as  yet  only  predisposed.  Many  physi- 
cians recommend  it  as  the  best  means  of  preventing  the  outbreak 
of  tuberculosis  in  the  predisposed  individual.  Now,  while  fully 
realizing  its  valuable  therapeutic  effects  in  many  other  diseases,  I 
consider  the  bicycle  ill-adapted  either  to  the  cure  or  the  prevention 
of  pulmonary  tuberculosis.  There  are  two  great  dangers  connected 
with  the  use  of  the  bicycle  for  any  one  whose  lungs  are  already 
affected  or  in  danger  of  becoming  so.  One  is  the  tendency  to 
overdo,  the  other  the  danger  of  taking  cold.  The  excess  of  mus- 
cular exertion  results  in  an  unhealthful  waste  of  tissue  which,  in 
the  tuberculous  individual,  is  replaced  with  more  difficulty  than  in 
others.  Bouchard,  of  Paris,  has  repeatedly  demonstrated  that  an 
excess  of  waste-products  renders  [an  individual  more  liable  to 
succumb  to  infectious  diseases,  especially  tuberculosis.  Persons 
predisposed  to  this  disease  often  have  a  rather  feeble  heart-action, 
and  such  are,  of  course,  in  great  danger  if  they  put  too  much  strain 
upon  the  heart.  Mendelsohn '  cites  several  cases  of  sudden  death 
from  this  cause.  The  bent-over  attitude  is  especially  injurious  to 
pulmonary  invalids.  Any  one  who  has  practised  cycling  himself 
must  acknowledge  how  easily  and  imperceptibly  one  overtaxes  his 
powers,  and  how  almost  unawares  one  gets  in  a  profuse  perspira- 
tion. One  is  then  liable  to  become  quickly  chilled  when  stopping 
to  rest  or  cool  off,  or  if  obliged  to  stop  to  fix  something  about  the 
wheel.  Herein  lies  the  second  danger  to  persons  who  have  reason 
to  be  especially  careful  to  avoid  nasal  and  bronchial  catarrhs, 
which,  in  the  consumptive  or  the  predisposed,  have  such  an  unfor- 
tunate tendency  to  descend  into  the  deeper  air-passages.  Lastly, 
the  nervous  strain  which  all  novices  undergo  while  learning  to 
ride  I  cannot  help  considering  injurious  to  a  relatively  weakened 
or  weak  constitution.  If  cycling  must  be  done,  I  consider  the 
tricycle  or  four-wheeled  vehicle  propelled  by  some  easily  managed 
motor,  as  recommended  by  Gihon,"  the'  safer  machine  for  the 
pulmonary  invalid. 


'  Mendelsohn,  *'  Deutsche  med.  Wochenschrift,"  April  30  and  June  18,  1896. 
*  Gihon,  "The   liicycle    in    its   Sanitary   Aspect,"  "New  York  Medical    Record, " 
Oct   3,  l8c)(). 


IM 


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292 


PULMONARY   TUBERCULOSIS. 


m 


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I  1,' 


As  I  stated  abovt,  I  think  a  strict  supervision  of  the  phthisical 
patient  is  almost  impossible  in  an  open  health  resort.  Unless  the 
patient  is  exceptionally  situated  and  very  prudent,  he  has  little 
chance  to  be  benefited  in  such  a  place.  If,  on  the  other  hand,  the 
patient  is  a  convalescent,  and  has  been  taught  how  he  should  live, 
with  a  view  to  getting  well,  by  his  physician  or  in  the  sanatorium, 
the  health  resort  may  well  offer  him  an  opportunity  to  complete 
his  cure. 

Fremy,^  considers  these  open  health  resorts  also  good  places  for 
the  scrofulous  and  the  predisposed  to  consumption  ;  but  it  seems 
to  me  essential  that  any  one,  even  if  only  predisposed  to  tubercu- 
losis, should  always  subject  himself  to  the  guidance  of  a  physician 
in  an  open  resort  as  well  as  at  home.  Many  an  intercurrent 
trouble  may  thereby  be  avoided. 

That  in  open  health  resorts,  in  spite  of  endeavors  on  the  part  of 
the  municipal  authorities,  one  is  not  free  from  the  danger  of  con- 
tracting a  tuberculous  disease,  and  that  there  is  much  chance  of 
reinfection,  I  have  shown  by  the  reports  kindly  sent  to  me  by 
Drs.  Ballestre  and  Atkins,  and  which  I  reproduced  on  page  37.  If 
we  compare  these  reports  with  those  from  Goerbersdorf  and  Fal- 
kenstein  (see  page  311),  which  show  not  only  the  absolute  freedom 
from  danger,  but  the  real  sanitary  advantages,  we  will  see  how 
much  safer  and  better  places  are  the  latter  to  go  to  to  be  cured  from 
a  pulmonary  disease.  I  am  sorry  to  say  that  in  some  of  our 
resorts  here  in  the  United  States  similar  conditions  prevail  to  those 
of  Europe.  Recent  personal  inquiries  in  some  of  the  boarding 
places  in  the  Adirondacks,  where  consumptives  congregate,  outside 
of  the  jurisdiction  of  the  sanatoria,  revealed  to  me  the  fact  that 
these  places  constitute  not  infrequently  veritable  centres  of  infec- 
tion. In  some  States,  much  frequented  by  tuberculous  patients, 
there  exists  a  popular  feeling  that  with  the  influx  of  pulmonary 
invalids  there  is  a  danger  of  consumption  becoming  "  endemic." 
In  California,  for  example,  an  attempt  has  been  made  to  restrict 
the  immigration  of  consumptives  into  that  State  by  legislative 
procedures.  This  Draconian  endeavor  to  settle  the  question  of 
prophylaxis  of  tuberculosis  did  not  have  any  success,  and  justly 
so.  Education,  judiciously  and  strictly  enforced  laws,  and  the 
multiple  creation  of  sanatoria,  especially  for  the  poorer  classes,  will 
achieve  more  good  and  do  no  harm. 


>  Fr^my,  Communication  au  Congris  de  la  Tuberculose,  Paris,  1888. 


u 


CONSUMPTIVES   IN    HEALTH    RESORTS,   SPORTS,   ETC. 


293 


In  the  interest  of  all  it  is  to  be  hoped  that  the  sanitary  authori- 
ties of  all  so-called  health  resorts  for  consumptives  will  soon 
succeed  in  enforcing  such  laws  as  will  make  of  these  places  what 
their  name  implies — resorts  for  health-seeking  people,  where  there 
will  be  no  danger  of  reinfection  or  chance  of  contracting  a  new 
disease.  Then  the  convakscent  or  incipient  tuberculous  patient 
may  go  to  these  resorts,  place  himself  under  the  care  of  an  experi- 
enced phthisio-therapeutist  (and  there  are  many  in  most  of  these 
places  in  Europe,  as  well  as  in  the  United  States),  and  complete  his 
cure  under  the  guidance  of  his  new  medical  adviser. 


(I 

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I 


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CHAPTER  XXII. 

THE  TREATMENT  OF  CONSUMPTIVES  IN  SPECIAL 

HOSPITALS. 

The  special  hospital  serves  its  most  useful  purpose  by  gathering 
in  and  caring  for  advanced  cases,  or  receiving  others  from  which 
the  most  suitable  for  sanatorium  treatment  could  be  selected.  The 
treatment  />erse  in  a  special  hospital  for  consumptives  need  not,  and, 
of  course,  should  not,  differ  materially  from  that  instituted  in  a 
sanatorium,  which  has  been  dealt  with  in  detail  in  the  preceding 
pages.  But,  since  the  special  hospital  is  situated  in  or  near  a  city, 
in  it  much  that  can  be  had  with  ease  in  the  country  sanatorium 
can  only  be  obtained  with  difficulty. 

The  first  requisite  for  the  special  hospital  is  a  location  as  quiet 
as  possible.  The  building  should  be  erected  on  high,  porous 
ground,  and,  of  course,  in  accordance  with  the  modern  conception 
of  hygiene  and  sanitation.  While  many  of  the  patients  will  per- 
haps be  in  bed  most  of  the  time,  there  should,  nevertheless,  be 
plenty  of  verandas  and  balconies,  wide  enough  to  hold  beds  or 
couches,  which  can  be  placed  on  them  on  warm  days  with  t^'-'r 
inmates.  In  a  city  hospital  for  consumptives  it  will  be  well-nigh 
impossible  to  have  a  separate  room  for  each  patient,  but  too  large 
wards  also  have  their  disadvantage.  Large  rooms  for  from  four 
to  six  patients,  with  a  number  of  single  ones  for  special  cases, 
seem  the  best  arrangement  for  such  an  institution.  The  temper- 
ature throughout  the  hospital  should  rarely  be  higher  than  65°  F., 
and,  as  much  as  possible,  uniform  throughout  the  establishment. 
In  winter  as  well  as  in  summer  the  atmosphere  of  the  rooms  must 
be  frequently  renewed  by  opening  the  windows,  or  by  ventilators. 
It  seems  to  me  that,  what  has  been  recently  instituted  by  Unter- 
berger'in  the  Military  Hospital  of  Zarskoje  Sselo,  near  St.  Peters- 
burg, would  be  an  excellent  addition  to  the  equipment  of  a  special 
hospital.      Pine-trees,  planted    in    tubs   of  wet    sand,  are   placed 

'  Unterlierger,  "  Ueber  .Scrophulose,  Tuberkulose  und  Phthisic  und  die  Behandlung 
in  Ilaus-Sanatorien,"  St.  Petersburg,  1897. 

294 


'^noimaaoatBtsoKx 


THE   TREATMENT  OF   CONSUMPTIVES    IN   SPECIAL    HOSPITALS.      295 

throufjhout  the  hospital,  more  numerously  in  the  bedrooms  and 
sitting-rooms.  Toward  evening,  when  the  odor  of  the  pine  grows 
weak,  the  trees  are  sprayed  with  the  following  solution  : 

K.     01.  piiii  silv.  (Scotch  fir), 10. o 

01.  terebinlliin.  pur., 30.0 

Aq.  font., 300.0 

Through  this  combination  the  air  becomes  more  impregnated 
with  ozone,  and  for  a  consumptive  to  live  and  take  frequent  respir- 
atory exercises  in  such  an  atmosphere  is  certainly  beneficial.' 

One  or  more  pneumatic  cabinets  should  also  belong  to  the 
equipment  of  an  institution  destined  to  treat  pulmonary  diseases. 

In  the  special  hospital,  where  the  majority  of  tuberculous 
patients  are  in  the  advanced  stages,  and  where  they  will  probably 
remain  until  they  die,  special  precautions  nui.st  be  taken  in  view  of 
the  sometimes  utter  helplessness  of  these  patients.  All  that  has 
been  said  concerning  the  expectorations  and  other  secretions  in 
chapter  iv  applies  to  special  hospitals  as  well  as  to  the  sanatorium. 
Frankel's  mask,  as  a  protection  against  the  expulsion  of  bacilli, 
should  be  worn,  whenever  practicable,  in  the  wards  (see  page  44). 
As  additional  precaution  in  a  city  hospital  for  consumptives  I 
would  suggest,  besides  the  disinfection  of  the  patient's  clothing 
and  the  supplying  of  others  in  the  meantime  (a  practice  now  in 
vogue  in  all  well-regulated  hospitals),  a  special,  hygiene  for  the 
protection  against  reinfection  and  the  possible  transmission  of 
their  disease  to  the  hospital  attendants.  It  should  be  the  duty  of 
the  nur.se  in  charge  to  make  the  rounds  at  stated  intervals  among 
the  patients  assigned  to  her  or  his  care,  not  only  for  the  purpose 
of  looking  after  their  wants,  but  to  see  that  they  have  not,  owing 
to  their  feebleness  or  carelessness,  expectorated  where  the  sputum 
may  constitute  a  danger.  No  person  should  be  employed  in  the  city 
special  hospital  for  consumptives  without  being  of  a  strong  con- 
stitution and  free  from  hereditary  predisposition  to  tuberculous  dis- 
eases. A  careful  physical  examination  by  the  chief  of  the  respec- 
tive service  should  determine  whether  or  not  the  applicant  may  be 


I 


i 

1.  '■■' 


m 


*  Richet  and  Ilericourt  haA  three  iloj's,  previously  inoculated  with  tuberculosis,  inhale 
turpentine  vafKus  for  an  hour  every  four  or  five  days,  with  tlie  result  that  two  were  still 
alive,  nine  months  later,  while  the  control  animals  all  died  in  about  thirty-live  days. 
Ilenoctjue  thinks  there  is  a  decided  therapeutic  value  in  the  ozone  generated  in  turpen- 
tine vapors. — Paris  See.  de  Biologic,  Nov.  12,  189S. 


'ii. 


; 


t      _ 


296 


PULMONARY   TUBERCULOSIS. 


admitted  to  nurse  tuberculous  patients.  Should  any  of  the  nurses 
feel  ill  they  should  report  at  once  to  the  physician.  If  their  illness 
is  of  a  serious  character  and  not  tuberculous,  they  should,  of  course, 
be  treated  somewhere  else,  since  where  there  are  many  consump- 
tives in  the  last  stages  there  may  remain,  in  spite  of  all  precau- 
tions, some  danger  of  infection.  When  suffering  from  colds  the 
nurses  should  not  be  allowed  to  attend  to  their  service.  I  still  re- 
member with  gratitude  that,  in  my  early  student  days  in  Paris, 
Professor  Debove  made  it  a  rule  not  to  allow  any  student  with  a 
coryza  or  bronchitis  to  enter  the  tuberculous  wards,  the  atmos- 
phere of  which  he  knew,  in  those  days,  to  be  laden  with  micro- 
organisms of  all  kinds,  and  especially  with  the  tubercle  bacilli. 

Physicians  and  nurses,  before  entering  upon  their  rounds  and 
duties  among  the  patients  of  a  special  hospital  for  consumptives, 
should  put  on  long  linen  coats,  and  should  wash  their  hands  before 
and  after  leaving  the  wards. 


CHAPTER  XXIII. 

THE  TREATMENT  OF  AMBULANT  TUBERCULOUS 

PATIENTS  IN  PRIVATE  AND  DISPENSARY 

PRACTICE. 

There  cannot  be  much  difference  in  the  treatment  and  manage- 
ment of  the  tuberculous  patient  able  to  come  to  the  physician's 
office  or  to  the  dispensary.  The  instructions  given  to  one  are 
applicable  to  the  other.  The  dispensary  situated  in  the  city, 
attached  to  the  reception  hospital  or  existing  independently  of  it, 
is  a  most  important  institution  for  helping  to  solve  the  problem 
of  dealing  with  the  consumptive  poor  who  are  not  sick  enough 
to  enter  a  special  hospital  or  sanatorium.  In  the  Lung  Depart- 
ment of  the  New  York  Throat  and  Nose  Hospital  I  had  the 
satisfaction  to  see  how  much  good  can  be  accomplished  by  a  well- 
regulated  dispensary  service  devoted  exclusively  to  the  treatment 
of  these  unfortunates.  I  emphasize  the  word  frenti/ient,  and  I  mean 
thereby  not  only  administering  medicine,  but  teaching  them  the 
hygienic  and  dietetic  principles  which  their  cases  demand. 

Since  it  is  often  impossible  for  the  ambulant  tuberculous  patient 
to  present  himself  daily  at  the  office  or  at  the  dispensary,  as  many 
of  this  class  of  patients  are  able  or  obliged  to  work,  it  is  well  to 
provide  them  with  printed  instructions.  These  should  be  written 
in  as  comprehensible  and  untechnical  language  as  possible,  and 
should  not  be  too  difficult  for  a  patient  with  little  or  no  means  to 
carry  out.  It  may,  perhaps,  not  be  amiss  to  reproduce  here  the 
instruction  card  which  I  compiled  for  my  private  practice  and  also 
for  my  out-door  service  at  the  New  York  Throat  and  Nose  Hos- 
pital (Lung  Department) : 


« 1 


Ih 


I  i' 


m 


n 


297 


'   it'  ■ 


298 


PULMONARY  TUBERCULOSIS. 


Envelope  for  Dispensary  Use. 


s 

m 

1   . 

y^tfi  |M 

1  ' 

rf  IV 

^ 

f  |;1  P 

1' 

|i.j;ir| 

;.  1:  !  ;. 

% 

I  -  .. 

NEW  YORK  THROAT  AND  NOSE  HOSPITAL. 


JVo. 


OUT-DOOR  DEPARTMENT. 


Sen'ice  of  Dr. 


Instructions  for  Mr. 

1.  Read  the  inclosed  instruction-leaflet  carefully. 

2.  Keep  it  clean  by  replacing  it  in  the  envelope. 

3.  Bring  the  leaflet  when  you  call  at  the  dispensary. 


Date, 


Number  of  Patient.,    .    .    . 
.    .    .  Instructions  for  M  . 


Gknkral  Advice. 

Be  hopeful  and  cheerful,  for  your  disease  can  be  cured. 

Avoid  anxieties  and  worry  as  far  as  possible. 

The  best  occupation  for  a  sick  person  is  to  labor  to  get  well. 

Have  at  least  nine  hours'  sleep  in  the  twenty-four,  and  retire  early.  If 
you  have  to  work  during  the  week,  and  you  feel  as  if  you  do  not  get 
a  sufficient  amount  of  rest,  remain  in  bed  all  Sunday  morning  and 
get  thoroughly  rested. 

Live  as  much  as  you  can  in  the  open  air.  Do  not  be  afraid  of  cold 
weather;  only  on  very  windy  days  remain  in-doors. 

Remain  in  the  sunshine  as  much  as  possible,  bul;  always  protect  your 
head  ;  the  best  place  to  take  a  sun-bath  is  a  spot  sheltered  from  the 
wind  (in  front  of  the  open  window,  when  there  is  no  garden, 
seranda,  or  flat  housetop).  Extend  yourself  on  a  comfortable 
lounge,  witl^your  head  in  the  shade  and  the  body  bathed  by  the 
rays  of  the  sun  ;  remain  there  as  long  as  you  feel  comfortable. 

Take  your  breathing  exercises  as  you  have  been  directed  ;  always  breathe 
through  the  nose. 

Take  your  walking  exercises  regularly,  as  ])rescribed.  Never  walk  until 
you  are  tired,  and  avoid  getting  into  perspiration. 


mmti 


TREATMENT   OF   AMBULANT   TUBERCULOUS   PATIENTS. 


299 


Avoid  draughts,  dust,  and  dampness,  and  all  places  where  the  air  is  bad, 
such  as  theatres,  concerts,  crowded  meeting-places,  etc. 

Keep  at  least  one  window  always  open  in  your  bedroom.  Night  air  is  as 
good  and  in  cities  even  better  than  day  air. 

Never  sleep  nor  stay  in  a  hot  room.  Have  your  own  sleeping-r  jm  if 
possible,  but  always  have  your  own  bed,  which  should  be  freely  aired 
during  the  day-time.  In  cold  weather  you  may  have  a  fire  in  the 
room,  but  keep  the  window  wide  enough  open  not  to  have  the  room 
warmer  than  60°  to  65°  F. 

As  a  rule,  do  not  leave  the  house  until  one  hour  after  sunrise. 

Dress  yourself  comfortably,  but  not  so  heavily  as  to  hinder  your  move- 
ments ;  discard  chest-protectors,  for  they  only  tend  to  make  you 
take  cold  more  easily.  ^Vear  a  suit  of  good  woolen  under-garments, 
also  wear  woolen  socks  ;  keep  your  feet  dry  and  warm.  Never  go 
without  rubbers  in  rainy  weather. 

Always  expectorate  in  a  spittoon  filled  partially  with  water,  into  which 
you  have  put  one  part  of  carbolic  acid  to  twenty  parts  of  water  (five 
per  cent,  solution).  ^Vhen  you  cannot  conveniently  get  at  the 
stationary  spittoon,  use  your  pocket-flask.  You  should  never  be 
without  one. 

Never  swallow  your  expectoration  ;  never  use  the  same  handkerchief  to 
wipe  your  nose  which  you  use  to  wipe  your  mouth  after  having 
expectorated.  Always  cover  your  mouth  with  the  latter  while 
coughing  or  sneezing.     Never  kiss  any  one  on  the  mouth. 


!  • ,    1 


Directions  Concerning  Food,  Drink,  Stimulants,  etc. 

Live  on  a  mixed  diet — that  is  to  say,  meat,  fish,  vegetables  (especially 
spinach,  lentils,  etc.),  fresh  and  cooked  fruit,  plenty  of  fresh  milk, 
fresh  eggs;  all  sorts  of  easily  digested  fats  (not  i^ork),  especially 
butter.  Thick,  nourishing  soups  should  be  taken  with  the  principal 
meals.  Raw,  cho])ped  beef  is  especially  to  be  reconmiended.  Whole- 
wheat bread,  being  more  nourishing  than  white  bread,  is  to  be 
preferred. 

Eat  slowly,  chew  your  food  well,  take  the  milk  in  small  swallows  ;  take 
but  little  licpiid  during  and  shortly  after  meals.  Keep  your  teeth 
in  a  good  condition  by  brushing  them  after  each  meal. 

Never  take  any  alcoholic  beverages  i^wine,  beer,  or  liquor)  without 
special  consent  and  direction  c  the  physician.  Too  much  sweets 
(sugar,  pies,  pastry,  etc.)  should  also  be  avoided,  as  well  as  all 
kinds  of  fried  food. 

Do  not  use  tobacco  in  any  form  ;  smoking  of  cigarettes  is  particularly 
injurious. 


rl 


a 

5 


.1 


300 


PULMONARY   TUIIEKCULOSIS, 


Special  Diep. 


DiKFxTiONS  Concerning  Baths  and  the  Use  of  Cold  Water. 

Take  one  short  warm  bath  once  a  week,  followed  by  a  rapid  s])onging 
with  cooler  water  and  a  vigorous  rubbing  with  a  rough  towel. 

Special  Directions  for  the  Use  of  Coi.d  Water. 


I  !i 


Special  Directions  for  Hreathinc;  Exercises. 

Take   exercise   No.  .    .    .        Repeat  .    .    .  times.       Every    .    .    .  hour. 
These  exercises  are  to  be  taken  near  the  open  window  or  out-diiors. 

Special  Medical  Advice. 


Any  intercurrent  trouble,  such  as  indigestion,  diarrhcea,  consti])ation, 
increased  cough,  pain,  reddi.sh  expectoration,  or  hemorrhage, 
should  be  at  once  reported  to  the  physician.  Do  not,  however,  be 
alarmed  if  you  have  a  hemorrhage,  as  it  is  but  one  of  the  phases  of 
the  disease,  and  does  not  lessen  the  chances  of  recovery. 

A  careful  and  obedient  patient  has  ten  times  as  much  chance  of  getting 
well  as  a  careless  or  disobedient  one. 

M.D., 

AtUniiing-  Physician. 

Concert. ing  the  care  of  the  expectoration,  I  have  learned  that  with 
the  ambulaat  patients  the  simpler  the  instructions,  the  greater  is 
the  likelihood  of  their  being  carried  out.  The  following  is  a  copy 
of  the  leaflet  which  accompanies  the  aluminum  pocket-flask 
designed  by  me  and  illustrated  on  page  43 : 

"  All  expectoration — that  is  to  say,  spittle — contains  germs. 
Some  of  these,  especially  when  there  is  bronchial  or  lung  trouble, 
are  dangerous;  thus  it  is  best  to  be  careful  and  gather  the  expec- 
toration, of  whatever  nature,  and  destroy  it  before  harm  can  be 


TREATMENT   OF   AMBULANT   TUBERCULOUS   PATIENTS. 


30 » 


done  by  it.  To  this  end  pocket  .sputum-flasks  have  been  devised. 
They  are  destinetl,  in  all  cases  of  bronchial  and  lunj,'  affections,  to 
receive  the  expectoration  or  spittle,  which,  if  not  carefully  jjathered 
and  destroyed,  may  become  the  cause  of  spreading  disease  to 
others.  This  method  of  disposing  of  the  sputum  also  protects  the 
patient  him.self  from  taking  the  .same  germs  into  his  system  again, 
either  by  inhaling  dust  containing  particles  of  the  dried  sputum  or 
by  infecting  himself  locally  through  sores.  It  is  not  .safe  to  use  a 
handkerchief  to  spit  into,  since  in  this  way  an  infection  of  the  nose 
is  possible.  The  pocket-flask  has  an  hermetically  closing  cover, 
and  can  safely  be  carried  in  the  pocket.  It  can  be  easily  hidden 
in  the  folds  of  a  handkerchief,  and  thus  its  use  will  not  attract  any 
attention." 

Instruction  for  Use  and  Cleaning  tiik  Pockkt-flask, 

To  open,  take  the  flask  in  the  right  hand  and  press  the  thumb  against 
the  side  of  the  projecting  front  s])ring.  To  close,  press  the  cover 
down  with  the  inde.x  finger. 

To  empty  the  flask,  unscrew  the  top  and  pour  the  contents  into  the 
water-closet ;  or  fold  a  newsjiapcr  into  several  layers,  pour  the  con- 
tents on  to  this,  and  throw  the  whole  at  once  into  the  fire,  being 
careful  not  to  s\n\\  any. 

Rinse  the  flask  in  hot  water  and  wash  the  hands  immediately  afterward. 
In  case  the  washers  wear  out,  rei)lace  them  by  new  ones. 


The  pneumatic-cabinet  treatment,  such  as  described  on  page  220, 
is  of  especial  value  in  office  and  dispensary  practice.  Besides  its 
beneficial  effects  on  the  patient's  general  condition,  which  he  will 
realize  after  a  few  seances,  the  psychical  influence  which  such  treat- 
ment produces  on  the  consumptive's  mind  is  of  incalculable  value 
in  the  treatment  of  the  average  dispensary  patient.  He  sees  and 
feels  that  something  especial  is  done  for  him.  He  rapidly  gains 
confidence  in  his  physician,  and  his  hopes  for  recovery  increase. 
Whenever  possible,  the  ambulant  tuberculous  patient  should  be 
seen  at  least  twice  weekly. 


li 


CHAI'IKR  XXIV. 
TREATMENT  OF  CONSUMPTIVES  AT  THEIR  HOME. 

The  great  majority  of  tuberculous  patients  cannot,  for  various 
reasons,  be  treated  in  either  sanatorium,  special  hospital,  or  health 
resort;  and  for  these  their  home  will  be  the  only  place  to  seek  rest 
and  relief,  and  become,  if  possible,  restored  to  health.  To  be  brief, 
I  may  say  that  the  best  thing  to  do  under  such  circumstances 
would  be  to  imitate,  as  nearly  as  is  practicable,  the  treatment  out- 
lined for  the  sanatorium  patient.  This  will  be  possible  if  the 
patient  is  willing  and  socially  so  situated  as  to  have  at  his  com- 
mand all  the  comforts  and  surroundings  which  the  hygienic  and 
dietetic  treatment  necessitates.  Hut  such  patients  are  relatively 
few.  The  majority  of  consumptives  are  poor  or  have  c.ily  mod- 
erate means.  For  the  absolutely  poor  the  municipal  sanatoriimi 
or  special  hospital  is  the  only  place.  For  those  of  moderate  means 
I  will  endeavor  to  offer  a  few  suggestions  which  will  make  an 
imitation  of  the  sanatorium  treatment  possible — a*,  least,  in  a 
measure. 

The  largest,  pleasantest,  sunniest,  best-ventilated  room  should 
be  given  up  to  the  patient.  Drafts  should  be  avoided  as  far  as  pos- 
sible, but  this  precaution  must  not  be  carried  to  extreme  so  as  to 
make  the  patient  afraid  of  a  breath  of  fresh  air.  If  the  bed- 
room is  too  small  to  make  it  possible  to  place  the  bed  to  avoid  the 
direct  draft  from  the  open  window,  a  substantial  screen  should 
be  u.sed  as  a  protection.  The  carpet,  heavy  curtains,  and  super- 
fluous furniture  should  be  removed,  without,  however,  leaving  the 
room  cheerless.  Small  rugs  and  curtains  that  can  be  washed  may 
be  retained.  All  the  hygienic  rules  laid  down  in  our  chapter  on 
Prophylaxis,  concerning  precautions  with  the  e.xpectorations  and 
other  secretions,  as  well  as  not  raising  dust,  should  be  religiously 
adhered  to  in  the  private  home.  During  the  day  the  lounge  or 
reclining-chair  should  be  moved  near  the  open  window,  if  there  is 
no  porch  or  balcony.  In  summer,  or  on  not  too  cold  or  windy 
days  in  winter,  the  patient  may  be  placed,  warmly  wrapped,  on  his 

302 


i\ 


ES? 


TREATMENT   OF   CONSUMl'TIVES   AT    HOME. 


303 


chair  on  the  flat  roof,  protecting  his  head  from  the  sun  by  an 
umbrella  or  a  small,  improvised  tent.  If  there  is  a  yard  or  };arden, 
a  small  platform  of  boards  may  be  arranged  for  the  cliair  in  a 
spot  sheltered  from  the  wind.  A  plain  steamer-chair,  padded 
with  a  quilt  or  blanket,  will  answer  the  purpose  just  as  well  as 
a  costly  reclining-chair.  Another  good  and  simple  method  of 
carrying  out  the  "  Liegekur,"  or  rest  cure,  in  the  open  air  is  the  one 


=.__        f/' 


; 


!f 


Fig.  75. — Rkst  Curb  at  Homb. 

suggested  by  Daremberg.'  A  large  beach-chair  of  wicker-work, 
such  as  is  seen  in  our  fashionable  sea-side  resorts,  is  procured. 
After  the  seat  has  been  removed  the  inner  walls  are  lined  with 
padding.  A  leclining-chair  is  placed  with  its  back  in  the  interior, 
and  the  whole  arranged  so  that  the  patient  is  protected  from  the 
wind  and  sun.     There  tlie  patient  installs  himself  for  the  day,  with 

'  Daremberg,  "  Traitement  de  la  Phtisie  Pulmonaire,"  vol.  u. 


>f 


304 


PULMONARY  TUBERCULOSIS. 


ft.:!  . 


t       [■ 


his  books  or  writing-materials  at  his  side,  placed  on  a  little  tabie, 
on  which  his  meals  may  also  be  served.  The  accompanying  illus- 
tration (Fig.  75)  will  show  how  easily  such  an  arrangement  can  be 
effected.  Being  light,  the  whole  can  be  shifted  whenever  th  wind 
changes  and  according  to  the  position  of  the  sun,  so  that  the 
invalid's  body  may  be  bathed  by  the  rays  of  the  sun,  while  the 
head  remains  in  the  shade. 

Rest  cure,  breathing  exercises,  and  the  amount  of  walking  the 
patient  may  be  allowed  to  do,  should  be  regulated  each  day  by  the 
attending  physician. 

In  our  chapter  on  Preventive  Treatment  we  have  already 
spoken  '  f  the  often  excessively  dry  atmosphere  in  many  of  our 


HUMIDIFIER 

I  FLOOR   REOISTER 

WATDO  TANK 
3  SHEETS  OF 
OTTON  FELT. 


Fig.  76. 

American  dwellings,  and  ascribed  to  this  condition  the  frequent 
occurrence  of  nasopharyngeal  catarrhs.  In  the  room  mostly  jc- 
cupied  by  the  pulmonary  invalid  there  will  be,  perhaps,  no  need  of 
any  arrangement  to  combat  a  too  great  aridity,  since  the  patient  is 
suppo-sed  to  keep  the  window  open  most  of  the  time.  But  in  the 
other  rooms  where  he  may  have  occasion  to  remain  for  a  time,  and 
in  the  interest  of  the  health  of  his  friends  and  relatives  as  well,  the 
use  of  a  humidifier  will  make  the  atmosphere  less  arid,  and  a  lower 
temperature  will  suffice  to  rentier  the  rooms  comfortable.  A  more 
humid  atmosphere  will  especially  benefit  the  patient  if  he  is  inclined 
to  laryngeal  trouble.  • 

The  humidifier  of  which  I  give  an   illustration  (Fig.  76)  is  the 
invention  of  Dr.  Henry  J.  Barnes,  of  Boston,  Mass.     It  consists  of 


aassm 


■IUH>».'.J— aiiUJJ' 


TREATMENT   OF   CONSUMPTIVES   AT    HOME, 


305 


an  outer  case  covering  a  wall  or  floor  register,  with  a  tank  for 
water,  over  which  are  suspended  strips  of  cotton  felt  aggregating 
about  twelve  square  feet  of  evaporating  surface.  These  are  con- 
stantly wet  through  capillary  attraction,  and  impart  to  the  air  flow- 
ing between  them  from  one  to  twelve  quarts  of  water  in  twenty- 
four  hours,  depending  on  the  percentage  of  moisture  in  the  air  en- 
tering the  case.  To  further  illustrate  the  usefulness  of  the  humidi- 
fier, I  will  quote  from  Dr.  Barnes'  paper,  read  before  the  American 
Public  Health  Association,'  the  following  interesting  passage: 

"  During  sixteen  days  of  last  February  I  obtained  in  my  ofiice 
with  this  device  a  mean  of  53  per  cent,  relative  humidity,  with  ex- 
tremes of  67°  and  40°  in  a  mean  temperature  of  65.3°,  through  the 
evaporation  of  from  2  quarts  to  2  gallons  of  water  a  day,  the 
average  being  4  v<  quarts.  During  this  period  the  outside  mean 
temperature  was  32°  and  relative  humidity  73^  per  cent.,  with 
extremes  of  92°  and  50°. 

"  I  found  65"  perfectly  comfortable,  whereas,  without  the  artificial 
supply  of  moisture,  I  required  from  70°  to  71°  temperature. 

"  I  could  have  obtained  a  higher  mean  relative  humidity  by 
adding  more  strips  to  the  humidifier,  thus  increasing  the  area  of 
the  evaporating  surface  ;  but  this  would  be  attended  with  an  exces- 
sive deposit  of  moisture  on  the  window-panes,  either  in  the  form  of 
vapor  or  frost.  Where  single  window-sashes  are  in  use,  the  dew- 
point — or  the  saturation  of  the  cold  air  near  the  windows,  which 
causes  the  deposit  of  dew — takes  place  more  abundantly  than  where 
double  sashes  are  employed,  as  a  consequence  of  the  cool  air  being 
unable  to  hold  in  solution  the  volume  of  watery  vapor  that  exists 
in  the  warmer  air  of  other  parts  of  the  room.  At  zero  tempera- 
ture dew  begins  to  be  deposited  when  the  air  contains  but  .564 
grains  of  water  in  a  cubic  foot  ;  at  70°  temperature  it  takes  nearly 
sixteen  times  as  much  in  a  cubic  foot  to  cause  a  deposit.  This 
deposit  of  moisture  on  windows  serves  as  a  valuable  guide  in  de- 
termining the  number  of  sheets,  or  the  area  of  evaporating  surface, 
necessary  to  maintain  a  jjroper  relative  humidity  in  any  particular 
room  where  artificial  hydration  is  employed.  When  the  required 
area  of  evaporating  surface  is  once  known,  the  apparatus  works 
automatically.  If  the  o-'tside  air  supplying  the  furnace  is  com- 
paratively warm  and  moist,  but  little  water  is  extracted  from  the 


i 


'■'\-\ 


■':  1-  * ;  ll,  1 


Hi 


^H 


n 


'    i  ' 


-  'tl 


'  "  riie  Arid  Alriiosiilu'ic  of  (  )ur  Houses  in  Winter,"  1898. 


30 


3o6 


PULMONARY  TUBERCULOSIS, 


l!#l! 


sheets  in  its  passage  to  the  room  ;  if  cold  and  dry,  it  takes  water 
from  the  sheets  with  great  rapidity." 

How  a  hydrotherapeutic  arrangement  can  easily  be  improvised 
at  home  with  the  aid  of  an  English  bath-tub,  a  wooden  chair,  and 
a  pitcher  ur  watering-pot,  has  already  been  described  (page  232). 
The  friend,  relative,  or  nurse  intrusted  with  the  care  of  the 
patient  should  always  sleep  in  another  bed,  and,  if  possible,  in 
an  adjoining  room.  He  or  she  alone  should  be  responsible  to  the 
physician.  All  interference  of  well-meaning  but  often  ill-advised 
friends  should  be  strictly  forbidden.  Only  the  food  and  such  deli- 
cacies as  are  ordered  by  the  physician  should  enter  the  room. 
Short,  pleasant  visits,  especially  of  congenial  persons,  will  do  the 
patient  good;  but  all  persons  for  whom  he  has  a  dislike,  or  who 
excite  him,  should  be  kept  away  as  much  as  possible. 

If  the  patient  is  too  weak  to  leave  the  bed,  cuch  an  arrangement 
with  pine-*^rees  as  has  been  described  in  the  chapter  on  Special 
Hospitals  on  page  295,  will  be  a  pleasant  and  useful  addition  to  the 
sick-room.  If,  on  the  other  h^.nd,  the  patient  is  in  the  incipient 
state,  convalescent,  or  strong  enough  to  go  to  the  physician's  office, 
the  pneumatic-cabinet  treatment  should,  if  possible,  be  applied  daily. 

As  in  sanatoria,  so  at  home  the  pulmonary  invalid  should  spend 
most  of  his  time  trying  to  get  well.  To  keep  him  in  good  cheer 
will  be  the  task  of  his  companions  and  friends,  but  to  see  that  he 
carries  out  with  greatest  regularity  all  that  is  required  of  him  in 
regard  to  treatment  and  prevention  will  also  become  one  of  their 
important  duties.  Carelessness  with  the  expectoration  should  never 
be  tolerated  under  any  circumstances ;  neither  should  the  patient  be 
allowed  to  indulge  in  anything  forbidden  by  the  physician,  as,  un- 
less the  latter  has  absolute  control  of  all  that  concerns  the  hygienic, 
dietetic,  and  symptomatic  treatment,  a  cure  in  a  private  home  cannot 
be  hoped  for.  In  many  cases  an  instruction-leaf  for  each  day,  left 
in  the  hands  of  the  nurse,  will  assure  a  better  care  of  the  patient. 

The  treatment  of  tuberculosis  in  a  private  home  by  the  family 
physician  can  and  should  be  prophylactic  in  the  broadest  sense  of 
the  word.  It  is  the  family  physician  who  will  see  the  incipient 
cases  first;  it  is  he  who  will  know  or  discover  the  predisposition  to 
tuberculosis  of  any  member  of  the  family.  Through  a  wise  and 
judicious  treatment,  instituted  in  time,  the  family  physician  will 
thus  cure  an  incipient  tuberculosis,  and  prevent  a  predisposed 
person  from  acquiring  the  disea.se. 


M>v 


iRm 


es  water 

provised 

lair,  and 

ige  232). 

of    the 

sible,  in 

le  to  the 

-advised 

uch  deli- 

e    room. 

1  do  the 

;,  or  who 

ngenient 
n  Special 
on  to  the 
incipient 
n's  office, 
ied  daily. 
Lild  spend 
od  cheer 
e  that  he 
3f  him  in 
e  of  their 
luld  never 
patient  be 
in,  as,  un- 
hygienic, 
lie  cannot 
li  day,  left 
le  patient, 
he  family 
t  sense  of 

incipient 
josition  to 

wise  and 
iician  will 
edisposed 


i' 


CHAPTER  XXV. 

SPECIAL  INSTITUTIONS   FOR  THE  CONSUMPTIVE  POOR  ; 

CARE  OF  CONSUMPTIVES  BY  THE  AUTHORITIES; 

THE  SOCIAL  PROBLEM  OF  TUBERCULOSIS. 

We  now  come  to  the  subject  of  special  institutions,  such  as 
hospitals,  sanatoria,  dispensaries,  etc.,  for  the  exclusive  treatment 
of  the  consumptive  poor. 

To  my  mind,  the  multiple  creation  of  such  institutions  will 
solve,  more  than  anything  else,  the  difficult  problem  of  how  to 
reduce  the  mortality  from  tuberculosis  and  prevent  its  spread  in 
general.  How  true  this  is  has  been  shown  in  no  other  country  as 
well  as  in  England.  It  is  there  that  the  idea  of  special  hospitals 
and  sanatoria  for  the  consumptive  poor  originated.  The  Royal 
Hospital  for  Diseases  of  the  Chest  and  the  Brompton  Hcspital  of 
London  were  the  first  institutions  of  this  kind  which  opened  their 
doors  to  the  tuberculous  patient  without  means.  While  the 
marvelous  reduction  of  the  mortality  from  tuberculosis  in  England 
must  be  in  part  ascribed  to  the  generally  improved  sanitary 
condition  of  the  country,  I  claim  that  a  good  deal  is  due  to  the 
workings  of  these  and  similar  institutions  now  for  many  years  in 
operation  in  England.  I  am  indebted  to  Dr.  Tatham,  the  statis- 
tical superintendent  in  the  Registrar-General's  office,  for  the  fol- 
lowing interesting  statistics  showing  the  reduction  of  mortality 
from  phthisis  pulmonalis: 

The  death-rate  per  million  of  the  population  of  England  and 
Wales  from  pulmonary  tuberculosis — 


111  1S70  was 

"  1S75  " 

"  1880  " 

"  1S85  " 

"  l8i)0  " 


2410 
2202 
1869 
1770 
1682 


In  1S93  was 1468 

"  1S94  " I3«S 

"  1S95  " '39S 

"  lSi)6  " 1307 


If  the  relatively  few  institutions  of  this  kind  have  been  instru- 
mental in  doing  so  much  good,  what  might  not  be  accomplished 
by  multiplying  these  special  hospitals  and  sanatoria  for  consump- 

307 


i  i 


111 


308 


PULMONARY   TUBERCULOSIS. 


A  visit  to  a 

tenement 

hunie. 


Average 

life  of  an 

honest 

laborer 

who  is 

tnbercu- 

lous. 


tives  all  over  the  world  !  That  there  is  a  great  and  urgent  need  of 
such  establishments,  especially  in  and  near  the  large  centres  of 
population,  no  one  who  has  any  experience  with  the  consumptive 
poor  of  any  large  city  will  dare  to  deny ;  and  that  the  majority 
of  general  hospitals  are  ill-adapted  to  the  treatment  of  tuberculous 
patients  is  also  too  well  known  to  need  repeating  here.  The 
description  of  the  life  of  a  poor  consumptive  before  and  after  his 
admission  into  the  general  hospital  will  constitute  the  best  plea  for 
sanatoria  for  the  poor. 

Let  us  begin  by  a  visit  to  the  districts  in  whose  narrow  streets, 
crowded  with  humanity,  most  of  the  poor  tuberculous  patients 
live.  We  make  our  way  into  a  house  through  the  little 
world  in  rags  playing  on  the  sidewalk.  The  hallways  are  dark, 
and  the  odor  indicative  of  crowded  and  unclean  rooms  greets 
us.  We  ascend  one  or  many  flights  of  stairs,  in  the  rear  or  in  the 
front — it  makes  little  difference.  There  lives  Mr.  So-and-So  with 
his  wife  and  several  children.  They  occupy  two  rooms,  rarely 
three;  but  only  one  receives  direct  light  and  air.  And  in  these 
few  rooms  live,  cook,  eat,  sleep,  and  often  work  from  eight  to  ten 
human  beings. 

We  inquire  after  the  patient,  and  find  him  lying  on  a  couch  or 
bed  in  a  dark  bedroom.  We  examine  him  and  find  him  suffering 
from  pulmonary  tuberculosis  in  the  last  stages.  On  examining 
the  other  members  of  the  family  we  find  one  or  two  of  them 
already  "  touched  "  by  the  deadly  germ. 

How  easy  it  is  for  this  infection  to  take  place  in  close  and 
unclean  quarters  occupied  by  ignorant  or  careless  people  has 
been  already  fully  described. 

Of  the  natural  defense  against  tuberculosis,  which  is  inherent  in 
all  robust  and  healthy  individuals,  little  can  be  expected  among 
the  inhabitants  of  these  tenement  districts ;  for,  alas !  they  are 
mostly  underfed,  and  their  unhygienic  surroundings  are  ill-adapted 
to  increase  their  power  of  resistance  to  disease. 

Let  us  take,  for  individual  illustration,  the  case  of  an  honest 
laborer  who  has  the  misfortune  to  become  tuberculous  and  finally 
phthisical.  Me  will  at  the  onset  seek  the  advice  of  his  family 
physician.  Presuming  that  a  correct  diagnosis  has  been  made, 
the  physician  is  likely  to  prescribe,  with  the  usual  remedies  just 
then  in  vogue,  also  a  few  weeks  of  rest.  This,  under  the  most 
favorable  circumstances,  means  a  consumption  of  a  part  of  the 


asK 


THE   CONSUMPTIVE   POOR   IN   GENERAL   HOSPITALS. 


309 


rarely 


savings.  After  a  while,  tiie  patient,  seemingly  improved,  resumes 
his  former  occupation  ;  but  the  improvement  is  not  lasting.  He 
is  again  and  again  obliged  to  take  a  rest.  The  intervals  between 
the  periods  of  work  become  longer  and  longer.  Instead  of  the 
physician,  the  nearest  dispensary  is  visited,  for  there  has  been  too 
great  a  drain  already  on  the  little  capital  put  aside  during  better 
days.  At  last,  unable  to  work  at  all,  he  stays  at  home  until  forced 
to  seek  admission  to  one  of  the  public  hospitals. 

A  large  number  of  general  hospitals,  supported  by  private  Sojoum  in 
chanty,  absolutely  reiuse  all  patients  surfermg  from  tuberculosis,  hospiwi. 
and  it  is  but  natural  that  the  attending  physicians  of  the  general 
municipal  hospitals,  if  not  obliged  to  accept  tuberculous  cases, 
should  also  avoid  crowding  their  wards  with  such  patients,  espe- 
cially if  there  is  a  likelihood  of  a  very  prolonged  stay.  Thus  the 
consumptive  often  obtains  admission  with  difficulty.  Finally 
admitted,  he  is  placed  in  one  of  the  general  wards.  His  neighbor 
to  the  right  may  have  typhoid  fever;  the  one  to  the  left,  a  pleurisy 
afrigore ;  opposite  him  may  be  a  rheumatic  or  a  fellow-consump- 
tive. If  the  physician-in-charge  is  in  favor  of  medication,  the 
patient  will  receive  the  latest  remedies  well  spoken  of  in  the  treat- 
ment of  tuberculosis.  If  the  doctor  is  skeptical  as  to  the  value  of 
medication  in  this  disease,  the  patient  may  or  may  not  receive  the 
special  diet,  and  the  rest  is  left  to  nature.  In  the  morning,  before 
the  arrival  of  the  visiting  physician,  the  poor  consumptive  inhales 
the  dust,  and  with  it  countless  numbers  of  pathogenic  microbes, 
raised  by  the  attendant  sweeping  the  ward  with  an  ordinary  broom 
instead  of  wiping  the  floor  with  a  moist  mop.  If  the  patient  has 
not  yet  his  mixed  infection  he  will  soon  get  it.  Instead  of  pass- 
ing most  of  his  time  in  the  open  air,  the  consumptive  in  our  gen- 
eral hospitals  is  almost  totally  deprived  of  this  essential  factor  in 
the  treatment  of  his  disease.  Should  he,  day  or  night,  ask  to  have 
a  window  open,  his  rheumatic  neighbor  would  very  strenuously 
object,  for  he  could  not  stand  the  draught.  Respiratory  exercises 
are  but  rarely  recommended,  for  the  physician  knows  they  are 
useless  in  the  ordinary  hospital  atmosphere.  At  meal-times  the 
consumptive  patient  eats  but  little.  The  frequent  anorexia  he  can- 
not overcome,  and  even  the  special  diet  does  not  tempt  him.  The 
acrotherapeutic  and  hydrotherapeutic  measures,  so  largely  and 
beneficially  resorted  to  in  sanatoria  to  overcome  the  loss  of  appe- 
tite, cannot  be  carried  out   in   a  general  hospital.     At  night  the 


sn 


'  i 


'!!  ■■ . 


3IO 


Danger  to 
patients 
sufl'eriiig 
from  acute 
diseases. 


11 


Sanatoria 
as  educa- 
tors. 


PULMONARY   TUnERCULOSIS. 


patient  sleeps  but  little.  He  is  either  kept  awake  by  his  own 
cough  or  that  of  his  neighbor.  The  stuffy  night  atmosphere  of 
the  ward  furthers  still  more  his  hyperhidrosis.  Thus  he  passes 
weeks,  sometimes  months,  until  a  fatal  termination  ends  his  suffer- 
ings ;  for  these  patients  rarely  enter  the  hospital  in  time  even  to 
hope  for  a  lasting  amelioration.  During  this  time  the  family, 
deprived  of  its  natural  supporter,  is  most  likely  to  have  become  a 
public  charge. 

How  does  the  presence  of  the  consumptive  in  the  general  hos- 
pitals affect  the  other  patients  suffering  from  acute  diseases? 
Leaving  aside  the  depressing  mental  effect  upon  these  patients, 
v-t  know  that  it  is  next  to  impossible  to  have  such  thorough 
hygienic  and  prophylactic  measures  in  a  general  hospital  as  are 
characteristic  of  the  sanatorium.  Is  not  the  patient  with  his 
pleurisy  a  frigorc  in  great  danger  of  having  his  acute  infection 
transformed  into  a  chronic  tuberculous  one  ?  And  the  typhoid 
fever  patient,  with  his  greatly  reduced  power  of  resistance,  may 
not  he  also  become  the  prey  of  the  bacillus  tuberculosis  ever 
present  in  our  general  hospitals  ? 

The  medical  and  sanitary  advantages  which  would  be  obtained 
by  the  creation  of  municipal  sanatoria  for  consumptives  are  evi- 
dent, but  these  are  not  all.  The  patient  with  incipient  phthisis, 
after  a  few  months'  practical  training  in  the  sanatorium,  will  have 
learned  how  to  take  care  of  his  expectoration,  to  avoid  auto- 
infection  or  the  communication  of  his  disease  to  others.  He  will 
have  learned  how  to  avoid  the  causes  which  may  aggravate  his 
condition,  and  acquired  such  hygienic  habits  as  to  have  the  best 
chance  to  become  and  remain  entirely  well. 

But  sanatoria  do  not  serve  only  as  educators  of  individuals,  but 
as  educators  of  communities  as  well.  In  the  villages  where  the 
two  largest  German  sanatoria  are  situated,  Goerbersdorf  and 
Falkenstein,-  the  mortality  from  tuberculosis  has  actually  decreased 
among  the  village  people,  being  now  one-third  less  than  before  the 
establishment  of  these  in.stitutions.  This,  no  doubt,  is  due  to  the 
example  set  by  the  inmates  of  the  sanatoria,  and  it  is  also  the  best 
proof   that   well-conducted    .sanatoria    for   consumptives    are   not 


1  Roempler,  "  Beitrage  zur  Lehre  von  der  chronischeii  Lungenschwindsuclit." 

2  Nahm,  "  Miinchener  nied.  Wochenschrift,"  No.  40,  1895. 


>  ■<ji;jiii»riiiliV  r. 


ssassssasxs 


SEpcissnsKiw 


li 


SANATORIA   AS    FDUCATORS. 


3-1 


I 


lis  own 
here  of 
i  passes 
suffer- 
even  to 
family, 
come  a 


centres  of  infection,  but,  on  the  contrary,  places  where    one  is 
safest  from  contagion.' 

To  uphold  these  statements,  I  will  reproduce  the  official  statis- 
tics of  the  village  of  Goerbersdorf  for  a  hundred  years  : 


Dkaius  kkom  I'iriiiisis  I'iimiinaiis. 


i7f>o-i799, 14 

1800-1809, 5 

1810-1819, 9 

1820-1829,  9 

1830-1S39 8 


1840-1849 6 

1850-1859 7 

1860-1869, 4 

1870-1S79 5 

1880-1889 5 


Statistics 
proving 
tliat  sana- 
toria arc  no 
ilanutr  to 
the  neiKli- 
borhooil. 


These  statistics  become  still  more  valuable  when  one  considers 
that  the  population  of  Goerbersdorf  has  doubled  in  the  last  twenty- 
five  years. 

Recently,  Dr.  Nahm  has  compiled  the  statistics  of  the  village  of 
Falkenstein.  Here  also  the  mortality  from  pulmonary  tubercu- 
losis has  been  reduced  from  18.9  per  cent,  before  the  establishment 
of  the  sanatorium  to  1 1.9  per  cent,  after  it  was  opened.  I  will  give 
the  statistics  of  Falkenstein  in  full  as  they  were  published  by  Dr. 
Nahm  : 

iJEArilS  FROM  rilrlllsIS  I'lI.MDNAl.IS. 


Before  the  Establishment  of  the  Sanatorutiii. 


1856-1858, .  . 

.  .17.2  per  100 

I859-I86I,  . 

•  7-7   " 

1 862- 1 864, 

.  .  -2.6   " 

1 865-1 S67,  .  . 

.  .  14.0   " 

IS68-I870,  .  . 

.   16.7   '• 

187I-IS73,  . 

.  .  21.0   " 

1874-1876, ,  . 

•  ■  33-3   " 

After  the  Kstahlishment  of  the  Sanatorium. 

1877-1879 17.0  per  too 

1880-1882 14.6   " 

1883-18S5 6.0   " 

1S86-1SSS,  ....  5.0   " 


1889-1891,  . 
1892-1894,  . 


•  139 
.  ivi 


Recalling  the  dreadful  mortality  from  tuberculosis  in  general 
and  military  hospitals,  among  the  Sisters  of  Charity  and  the  ordi- 
nary nurses,  as  reported  by  Debove,  Bergeret,  Lombard,  Cornet, 
Laveran,  and  Kirchner,"  induced  me  to  inquire,  when  visiting  the 
European  sanatoria,  whether  any  of  the  nurses  or  attendants  there 
had  ever  contracted  tuberculosis.  I  was  told  of  one  case  (in 
Reiboldsgriin).  A  seemingly  well  young  lady  had  entered  the 
sanatorium  as  nur.se  and  died  of  consumption  a  year  later.     Careful 


1  Knopf,  "Are  Sanatdria  fcir  Consumptives  a  Danger  to  the  Neighborhood?" 
"X.  Y.  Med.  Record,"  Oct.  3,  l8y6;  "  Revue  de  la  Tuberculose,"  Paris,  vol.  ill,  p|). 
313-319. 

'  Straus,  "  La  tuberculosa  et  sou  liacille,"  p.  453. 


t-\ 


^^:l 


312 


PULMONARY  TUBERCULOSIS. 


•''  pi 


4< ' . 


^iii 


^i    PI  i 


Expense  in 
American 


research  revealed  afterward  that  a  near  member  of  her  family  had 
died  previously  from  tuberculosis. 

During  his  many  years  of  service  at  the  Brompton  Hospital, 
London,  Dr.  Williams  had  not  seen  more  than  three  or  four  cases 
among  nurses  or  doctors  where  it  seemed  evident  that  pulmonary 
phthisis  had  been  contracted  there.  The  scrupulous  neatness,  the 
excellent  hygienic  condition,  and  the  thorough  precautions  against 
infection  from  the  expectoration  make  it  almost  impossible  to 
contract  the  disease  in  this  excellent  institution. 

At  Saranac  Lake,  the  great  American  sanatorium,  none  of  the 
twenty  to  twenty-five  attendants  have  ever  developed  tuberculosis. 

The  daily  expenses  of  a  well-equipped  special  hospital  or  sana- 
torium are  little  if  any  higher  than  those  of  a  general  hospital,  and 
the  results  obtained  there  are  certainly  much  better  than  anywhere 
else  with  this  class  of  patients. 

From  the  statistics  which  I  obtained  I  may  be  allowed  to  quote 
sanatoria,    tjjg  following  figures  to  Substantiate  what  I  have  said  in  regard  to 
expense  in  general   hospitals,  special  hospitals,  and  sanatoria,  and 
the  results  obtained  in  these  respective  institutions. 

The  daily  expense  at  the  Adirondack  Sanitarium  for  Consump- 
tives at  Saranac  Lake,  reported  by  Dr.  Trudeau,  is  $i.oo  to  Si. 25. 
Patients  pay,  however,  only  $5.00  per  week,  and  the  difference  is 
made  up  by  public  contributions. 

The  daily  expense,  reported  by  Dr.  Stubbert,  of  the  Loomis 
Sanitarium  at  Liberty,  N.  Y.,  which  has  a  most  modern  equipment, 
is  S1.43.  Some  patients  pay  $5.00,  others  from  $10.00  to  520.00^ 
according  to  the  location  of  the  rooms.  Like  the  Adirondack 
Sanitarium,  it  is  also  largely  supported  by  private  subscriptions. 

The  daily  expense  at  the  sanatorium  for  the  consumptive  poor 
at  Ruppertshain,  reported  by  Dr.  Dettweiler,  is  $0.61. 

The  daily  expense,  estimated  by  P.  .Straus,  for  the  Municipal 
Sanatorium  for  Consumptives  at  Angicourt,  France  (in  construc- 
tion), will  be  $0.82. 

Regarding  special  hospitals  for  consumptives,  I  was  enabled  to 
obtain  from  two  institutions,  appertaining  to  the  two  largest  cities 
of  the  United  States,  the  following  figures  :  At  St.  Joseph  Hospital 
for  Consumptives  of  New  York  the  average  cost  per  patient, 
reported  by  Dr.  Cauldwell.is  about  fifty  cents;  and  at  the  Chestnut 
Hill  (Philadelphia)  Hospital  for  the  Consumptive  Poor  the  average 
daily  expense,  reported  by  Dr.  Bacon,  is  about  forty  cents. 


EXPENSE    IN   GENERAL    HOSPITALS. 


313 


ily  had 


The  following  figures  relate  to  general  hospitals  : 


against 


Country. 

Rbportkd  bv 

HOSPITAI,. 

i 

< 

u 

si- 

>t/l 

>d 

< 
39* 

< 

^a 

Austria,*.   .   . 

■ 

Prof,  von  Schrotler. 

Vienna  General  Hos- 
pital. 

0 

AA'li 

35 
days. 

J0.35 

Baden 

f 
I 

/ 

Prof.  Biiumler. 

Dr.  F.  Parks 
Weber. 

Freihurg  Medical 
Clinic. 

Guy's  Hospital,  Lon- 
don, 

0 

J0!« 

'94* 

* ' 

1. 00 
0.92 

1 

Middlesex     Hospital, 

., 

., 

•75 

\ 

London. 

] 

St.  George's  Hospital, 

. . 

1.5a 

England,     . 

1 

The  Author, 

London. 
St.   Mary's    Hospital, 

London. 
St.  Thomas'  Hospital, 

London. 
London      Hospital, 

London. 

All  hospitals  in  Paris 

^^ 

•• 

1.25 

1-57 
1. 17 

0.66 

France,    .  . 

J 

under  the  charge  of 

i 

the  Assistance  Piib- 

I 

lique. 

f 

Prof,  Rosenstein. 

Leyden  General  Hos- 

., 

.. 

The 

Holland,  .   . 

{ 
f 

Prof.  Massaloiigo. 

pital. 
Verona  Major  Hospi- 

0 

greater 
part. 

34.03^ 

Italy 

{ 

Dr.  Ernest  de 
Verdi. 

tal. 
Milan  Hospitals. 

° 

•• 

0.38 

1 

I 

Prof.  Fiirbrinser. 

Berlin  General  Hospi- 

l-2-f. 

433!' 

47-5^ 

30 

0.65 

Prussia,    .   . 

Prof.  Mosler. 

tals. 
Greifswald  Medical 

0 

25ri 

'i-rl^ 

days. 

Clinic. 

( 
1 

Prof.  Eiohhorst. 

Ziirich  Medical  Clinic. 

\.(f!- 

37.5f' 

35.49:< 

•  • 

Switzerland, 

Prof.  Ininicrniann. 

Biivger-Hospital,  Basel. 

5ori 

36^ 

days. 

0.70 

Dr.  Nicolas. 

Neuchfttel  Hospital. 

0 

20.  K 

49,6^0 

( 

Dr.J.  N.Walker. 

Cook   Countv   Hospi- 
tal, Chicago,  III. 

0 

55.5f« 

20.4^ 

•• 

•  • 

\ 

Dr.  Brainerd. 

Los   Angeles  County, 

0 

,  , 

50< 

14,S 

1. 00 

1 

Hospital,  Cal. 

days. 

United  States 

'   The  Author. 

(1          ^ 

Alithe  New  York  City 
hospitals  under  the 
direction    of  the 
Cominissioii  of  Char- 
ities. 

■■ 

■■ 

1.16 

.,:.      5 


f^i>'  i 


'1 


The  results  obtained  in  sanatoria  for  the  tuberculous  poor,  or  inKesuUsob- 
those  institutions  where  the  patients  pay  only  a  certain  proportion  sanatorii'i 
for  their  maintenance,  are  virtually  the  same  as  those  obtained  insmnptive 
paying  institutions,  the   statistics  of  which   will  be  found  in  the 
concluding  chapter. 

The  Loomis  Sanitarium  at  Liljerty,  N.  Y.,  reiiorts  25  per  cent,  of  cures 
and  50  per  cent,  of  ameliorations  ;   70  per  cent,  for  early  cases. 


I- 


Il   ! 


314  PULMONARV   TUllERCULOSIS. 

The  Adiroiulack  (.'ottage  Sanitarimn  for  Consumptives  at  Saranac  Lake, 
N.  Y.,  reports  20  to  25  per  cent,  cures  and  30  to  35  per  cent, 
ameliorations. 

'I'he  Sharon  Sanitarium  near  Boston,  Mass.,  reports  25  i)er  cent,  of 
arrested  cases  and  a  nincli  larger  i)ercentage  of  improvenu-nts. 

The  Hahla  Sanatorimn  fci  the  Poor,  Finland,  reports  36.7  percent,  of 
cures  and  33  ])ercent.  ameliorations. 

The  Falkenstein  Sanatorium  for  the  Poor,  now  at  Ruppertshain,  Ger- 
many, reports  13  per  cent,  absolute  cures  and  77  per  cent, 
ameliorations. 

While  in  the  three  above-mentioned  American  sanatoria,  as  a  rule, 
only  patients  with  incipient  phthisis  are  admitted,  at  the  Chestnut 
Hill  Hospital  for  the  Consumptive  Poor,  in  Philadelphia,  patients 
even  in  the  very  advanced  stages  are  received.  Still  the  institution 
could  report  the  following  results  : 

Disch.irged  as  cured,       8      \ht  cent. 

Improved, ^'-'1  percent. 

Unimproved, 6^,  ner  cent. 

Died 17'^  percent., 

and  the  average  daily  expense  was  only  between  thirty  and  forty 
cents. 

It  may  not  be  unintere.sting  to  add  to  the  above  statistics  the 
results  obtained  in  public  sanatoria  devoted  exclusively  to  the 
treatment  of  scrofulous  and  tuberculous  children.  It  seems  that 
in  the  young  the  sanatoriimi  treatment,  especially  in  institutions 
situated  on  the  sea-shore,  is  particularly  successful.  Here  are  the 
statistics  of  five  institutions,  four  situated  in  France  and  one  in 
Denmark. 


Sir't-- 


Location. 


Reported  by 


MORTAI.- 
ITV. 


Curbs.   Improvhd. 


AVKRACK 

Stay. 


Ormesson,    .    .        .    . 

Dr. 

(aoul. 

8.2% 

34       '/r 

30  '/, 

7  inc 

Villiers, 

(* 

Vaquicr. 

8.8/. 

25-5  '/' 

34-4  '/' 

Forges-les-Bains,     .    . 

n 

Dnnienge. 

.       . 

50    '/'■ 

25       '/' 

12 

Arcaclion 

(. 

I.ales<iiie. 

29     % 

21.7 '/; 

45' 9  '/' 

Rcfsnaes  (Deninnrk), 

(t 

Sliepdcrn. 

25      fc 

42.4  '/< 

^Vz 

It  might  not  be  amiss  here  to  compare  the  economic  advantage 
of  early  sanatorium  treatment  with  the  usual  routine  hospital 
treatment  of  our  consumptive  poor.     Let  us  take,  for  illustration,  a 


;ic  Lake, 
er  cent. 

cent,   of 

ts. 

cent,  of 


ECONOMIC  ADVANTAGE  OF  EARLY  SANATORIUM  TREATMENT.     315 

comiminity  of  1,000,000  iiiliabitants.  With  an  average  death-rate 
of  25  per  1000,  one-fiftli  of  whom  die  from  tuberculosis,  the  com- 
munity would  lose  5000  a  year  from  this  disease. 

Some  sanatoria  claim  as  many  as  70  per  cent,  of  cures'  when 
the  patients  are  admitted  to  treatment  in  the  incipient  stages,  and 
I  have  reason  to  believe  that  these  figures  are  exact,  for  pulmonary 
tuberculosis  in  the  earlier  stages  is,  indeed,  one  of  the  most  curable 
of  all  chronic  diseases.  But  let  us  presume  a  percentage  of  fifty 
only.  Thus,  if  these  5000  would  have  been  placed,  at  the  onset  of 
their  di.sease,  under  proper  treatment  in  sanatoria,  2500  human  lives 
would  surely  have  been  saved.  Statistics  have  amply  shown  that 
tuberculosis  is  most  prevalent  among  the  poorer  classes.  The  rela- 
tion is  about  as  3  to  2.  I  believe  that  I  am  nearly  right  when  I 
say  that  of  those  5000  over  3000  at  least  are  of  the  poorer  classes, 
and  of  these  2000  have  died  most  likely  in  public  institutions. 

From  personal  experience,  gained  in  some  of  the  larger  general 
hospitals  in  the  United  States  and  I'Lurope,  I  have  learned  that  a 
tuberculous  patient  rarely  makes  a  continuous  stay  in  one  hospital. 
He  usually  improves  after  his  first  sojourn  and  leaves,  only  to  turn 
up  after  a  few  month';  in  the  same  or  another  hospital  for  a  second 
period  of  rest,  and  5,0  on.  Rut,  all  in  all,  the  time  he  spends  in 
general  hospitals,  to  which  he  is  usually  admitted  when  in  the 
advanced  stage,  i.;  rarely  less  than  fifteen  months. 

As  above  stated,  the  daily  expense  per  capita  in  the  general 
public  hospitals  of  the  city  of  New  York"  is  $1.16.  Thus  the 
patient  costs  the  municipality  up  to  his  death  $522,  aside  of  the 
money  expended  on  the  family  of  the  patient,  should  the  latter 
have  been  its  only  bread-winner. 

The  general  hospitals  claim  few  cures  of  pulmonary  tuberculosis, 
and  it  seems  almost  as  if  this  money  had  been  uselessly  spent, 
since  a  general  hospital  cannot  even  be  considered  a  safe  place  for 
isolating  a  consumptive.  If  the  same  patient  had,  for  example, 
been  treated  at  the  Adirondack  Cottage  Sanitarium  or  a  similar 
institution,  and  been  sent  there  at  an  early  period  of  his  disease,  he 
would  have  hatl  fifty  per  cent,  more  chances  of  recovery,  and 
would  have  cost  only  one  dollar  a  day,  and  that  during  a  period  of 
perhaps  only  from  six  to  nine  months. 


! 


1 

#•■ 

,''■ 

1 ' 

ii 

'  "Semi-annual  Report  of  the  Loorais  Sanitarium  for  Consumptives,"  1898. 
^  "  .Xiinual  Report  of  the  Commissioners  of  Public  Charities  and  Correction  of  the  City 
of  Xew  York." 


:..  ..I 

5:' 


3i6 


PULMONARY    TUHERCULOSIS. 


Results  t)h' 
taiiie<l  by 
niunicipal 
prophy- 
laxis. 


Thus,  200O  tuberculous  patients  treated  in  the  ^a-neral  liospitals 
in  the  city  of  New  York,  with  very  little  chance  of  beinj;  cured, 
but  with  much  chance  of  doinfj  harm  to  their  fjllpw-patients  suffer- 
ing from  acute  diseases, cost  the  city  Si. 044,000.  Treated  in  sana- 
toria or  special  hospitals,  with  twenty  to  fifty  per  cent,  chances  of 
recovery,  according  to  the  stage  of  their  disease,  and  even  if  we 
should  allow  them  just  as  long  a  stay  in  the  special  institution  as 
we  grant  to  the  advanced  cases  in  general  hospitals,  the  cost  would 
be  only  $890,000.  Thus,  with  a  saving  of  at  least  $150,000,  and 
the  saving  of  hundreds  of  lives,  countless  centres  of  infection 
would  be  extinguished  which  otherwise  would  endanger  the 
families  and  neighbors  of  the.se  tuberculous  invalids. 

Besides  all  this,  one  must  think  of  the  gain  to  the  commonwealth 
by  restoring  to  health  tiie  many  bread-winners  whose  families, 
under  the  present  conditions,  might  become  a  burden  to  the  com- 
munity. 

In  considering  the  economical  and  social  question  of  tuberculosis, 
one  must  also  bear  in  mind  the  fact  that  the  period  of  life  in  which 
consumption  is  mo.st  frequently  contracted  is  between  the  ages  of 
puberty  and  thirty.  Thus,  the  majority  of  these  sufferers  are  at  an 
age  in  whi'tu  they  should  be  of  the  greatest  use  to  society. 

We  Inv:?  dready  referred  to  the  sanatorium  as  an  educator  of 
the  tubercv.ious  individual  and  of  the  community,  and  as  an  insti- 
tution where  certainly  much  better  results  are  obtained  in  the 
treatment  of  tuberculous  patients  than  in  the  best  equipped  gen- 
eral city  hospital.  But,  we  repeat,  the  special  hospital  for  con- 
sumptives in  or  near  the  city  does  great  good  by  taking  even  the 
most  advanced  cases  away  from  the  poor  quarters  of  the  city. 

In  many  of  the  large  cities  the  improved  sanitary  conditions  of 
the  dwellings  of  the  poor,  combined  with  other  prophylactic  regu- 
lations, have,  no  doubt,  helped  to  decrease  the  mortality  from 
tuberculosis  in  a  marked  degree.  Foremost  among  these  cities 
-Stand  London,  Berlin,  New  York,  and  Philadelphia. 

What  gratifyuig  results  may  be  obtained  by  energetic  prophy- 
lactic work  on  the  part  of  the  boards  of  health  of  the  great  cities 
is  shown  by  the  very  interesting  report  of  Dr.  Hermann  Biggs,  the 
director  of  the  New  York  City  Department  of  Health.  In  an 
article  on  the  prevention  and  restriction  of  pulmonary  tuberculosis, 
which  appeared  in  the  June  "  Practitioner"  (London)  of  1898,  Dr. 
liiggs  produced  the  following  table,  showing  the  decrease  in  the 


MUNICIT'M,    I'KOI'IIVI.AXIS    AND    ISOLATION    IIOSI'ITAI^, 


i^7 


death-rate  from  all  tubercular  diseaRes  in  New  York  City  during  the 
past  ten  years : 


1SX6     tHS;  ,  188H  I  1889  I  1890 


Dealliratc,     .    .'4.42   4.06    3.99 '3.86   3.97 


1891 


356 


««9« 


1*93 


3-55   15' 


»94 


3.16 


1893     1896 


1897 


3.34 'j.or.  2.S5 


lint  no  matter  how  strict  the  prophylactic  measures  may  be,  they 
will  not  suffice  to  do  away  with  the  centres  of  infection  daily 
created  anew  in  the  tenement  districts.  There  must  be  places 
where  tuberculous  patients,  no  matter  in  what  stage  of  their  disease, 
can  find  treatment  and  shelter  at  all  times. 

A  beautiful  illustration  of  the  value  of  isolation  is  the  St.  Joseph  Vaiue 

■'  »       of  isdiatio 

Hospital  for  Consumptives  of  the  city  of  New  York,  where  1500 
patients,  co  Ming  fron  among  the  poorest  classes  of  the  population, 
are  received  annually,  most  of  them  in  the  very  last  stages  of  the 
disease.     Many  lives  are  thus  certainly  saved  indirectly. 

But  the  best  ultimate  results  in  combating  tuberculosis  are  not 
obtained  by  treating  the  adult  when  the  disease  has  already 
developed,  but  by  taking  hold  of  the  jiredisposed  or  tuberculous 
individual  at  the  very  earliest  moment  of  his  life.  In  other  words, 
not  only  the  prophylactic  and  curative  treatment  should  begin  with 
the  child  in  iitcro,  but  also  the  State  and  municipal  care. 

To  make  my  ideas  on  this  subject  clear,  ideas  which  I  have 
reason  to  believe  are  shared  by  the  majority  of  sanitarians,  I  can- 
not do  better  than  repeat  the  more  essential  part  of  what  I  have  said 
in  an  address,  delivered  in  August,  1898,  before  the  Thirteenth 
Annual  Conference  of  the  State  and  Provincial  Boards  of  Health 
of  North  America.' 

I  do  not  desire  to  discuss  here  the  prophyla.xis  in  regard  to  the 
procreation  of  a  tuberculous  progeny;  which  must,  according  to 
our  present  conceptions  of  law  and  ethics,  remain  the  delicate  task 
of  the  family  physician.  The  duty  of  the  sanitarian  and  the  gov- 
ernment in  regard  to  the  consumptive  poor  commences  with  the 
care  of  the  tuberculous  mother  after  conception.  All  I  may  be 
privileged  to  say  here  is  that,  according  to  the  experience  of  promi- 
nent obstetricians  (foremost  among  whom  I  wish  to  mention  my 


I 


'  "  .State  and  Municipal  Care  of  Consumptives,"  "  New  York  Medical  Record,"  Sept. 
24,  1898. 


318 


PULMONARY   TUUERCULOSIS. 


Mi    U 


Maternity 
sanatoria. 


two  late  and  much  regretted  teachers,  Professor  Lusk,  of  New 
York,  and  Professor  Tarnier,  of  Paris),  intervention  after  a  tuber- 
culous conception  for  the  purpose  of  cutting  short  the  duration  of 
gestation,  and  thus  saving  the  mother  d  life,  has  proved  disastrous 
in  the  majority  of  cases. 

By  proper  hygiene  and  ciet,  preferably  in  an  institution,  or,  at 
least,  under  the  careful  guidance  of  a  physician,  during  a  few 
months  before  and  after  confinement,  numbers  of  tuberculous 
women  and  their  children  have  been  lastingly  cured.  Thus  it 
seems  to  me  the  best  policy  for  the  government  would  be  to  create 
institutions  which  might,  perhaps,  justly  be  called  "maternity 
sanatoria,"  where  the  tuberculous  mother,  coming  from  our  tene- 
ment districts,  should  be  taken  at  least  a  few  months  before  her 
delivery,  and  should  remain  until  some  time  after  complete  re- 
covery from  her  childbed. 

The  beneficial  effect  on  the  woman's  and  cl.ild's  ccnstitutions 
through  such  an  arrangement  can  hardly  be  overestimated. 
Leaving  aside  the  physical  well-being  thus  largely  assured  to 
mother  and  child  at  a  period  wlicn  their  organisms  need  the  most 
tender  care,  the  hygienic  training  which  the  mother  will  have 
received  in  such  an  institution  will  be  of  lasting  utility  to  herself 
and  child,  to  the  family,  and  to  the  community. 

These  maternity  sanatoria  need  not  be  situated  at  a  great  dis- 
tance frcm  the  city.  All  that  would  be  essential  is  that  they 
should  be  erected  on  good,  porous  ground,  preferably  somewhat 
elevated  and  in  a  loca'ity  where  the  atmosphere  is  as  pure  as 
possible.  The  building.«  should  be  constructed  according  to  the 
principles  of  modern  obstetrical  science  and  modern  phthisio- 
therapy.  The  physician-in-charge  should  be  experienced  in  both 
the.se  branches  of  medicine. 

The  knowledge  gained  by  the  mother  in  the  maternity  sana- 
torium will,  in  all  probability,  suffice  for  her  to  bring  up  the 
infant  as  a  relatively  strong  child  aid  protect  it  from  the  dangers 
of  tuberculous  infection,  liut  the  inherited  predisposition  may 
still  remain,  and  at  t!ie  time  the  child  begins  to  go  to  school  the 
State  should  again  make  provisions.  I  Have  learned,  by  private 
inquiry,  that  a  pregnant  woman,  who  has  ''le  misfortune  to  be 
syphilitic  or  tuberculous,  has  great  difficulty  to  gain  admittance  to 
matv'inities  supported  by  private  contributions.  I  know  from 
official  sources  that  tuberculous  children  are  not  only  unwelcome 


1 


MATERNITY   AND   SCHOOL  SANATORIA. 


319 


to  tlu 


in  public  scliools,  but  are  not  infrequently  refused  admittance,  on 
the  ground  of  being  afflicted  with  a  contagious  disease.  The 
Michigan  State  Board  of  Health  recommends  that  persons  known 
to  be  affected  with  tuberculosis  of  the  lungs,  or  who  persistently 
cough  and  expectorate,  be  denied  the  privilege  of  the  school-room 
either  as  a  teacher  or  a  pupil.  If  I  am  not  mistaken,  it  was  in 
Toronto'  that  the  right  of  the  municipality  to  refuse  a  tuberculous 
c  lild  admission  to  i.he  public  school  was  tested  for  the  first  time 
before  a  court,  and  sustained  on  the  ground  of  the  contagious 
nature  of  the  disease. 

I  do  not  wish  to  question  the  wisdom  of  this  judgment,  but  I 
should  like  to  know  what  is  to  become  of  the  child,  if  his  parents 
are  too  poor  to  pay  for  private  instructions?  The  child  cannot 
return  to  the  public  schools,  for  its  disease  is  a  chronic  c.e  and 
may  last  for  years,  ^f  the  municipality  refuses  the  benefit  of  an 
education  in  the  ordinary  public  schools  to  such  a  child,  does  it 
not  become  an  imperative  duty  to  provide  special  schools  for 
tuberculous  children  ? 

Schools,  however,  in  the  ordinary  sense  of  the  word,  would  do 
but  little  good  to  such  a  child.  In  France,  Belgium,  and  some 
other  European  countries,  there  have  existed  for  years  sanatoria 
for  the  treatment  of  tuberculous  children,  maintained  by  the 
iTiunicipalities.  Attached  to  all  these  institutions  are  regularly 
established  schools.  To  provide  a  place  where  tuberculous  children 
and  the  children  of  tuberculous  parents — the  weaklings  of  the 
flock — shall  be  taken  care  of  becomes  the  duty  of  the  government. 
In  these  school-sanatoria  the  children  will  have  a  chanre  to  be 
cured,  if  possible,  of  their  disease  or  their  predisposition,  and  at 
the  same  time  they  will  receive  the  education  which  the  State  owes 
to  all  the  children  of  the  community.  The  niajority  of  these  school- 
.sanatoria  may  be  advantageously  placed  on  the  sea-shore,  for  it 
seems  a  well-established  fact  that  the  tuberculous  manifestations 
in  childhood,  which  are  most  frequently  observed  as  joint  tuber- 
culosii  or  tuberculosis  of  the  bones  or  of  the  glands,  do  remark- 
ably well  in  marine  climates. 

The  selection  of  such  children  for  sanatorium  treatment  would 
be  the  task  of  the  school  physician,  and  one  should  be  attached  to 
every  public  scnool.     He,  seeiuj^   the  children   daily,  in  order  to 


Sanatoria 
for  school 
chiklreii. 


1:1 


1 "  Medical  Week,"  Paris,  Sept.  14,  1894. 


320 


PULMONARY   TUBERP  '  .OSIS. 


ii 


s 
poor 


prevent  the  introduction  and  propagation  ol  acute  diseases,  will 
soon  discern  between  the  robust  and  well-nourished  and  the  weak, 
dyspeptic,  and  not  infrequently  underfed  pupils.  These  latter  will, 
ipso  facto,  always  be  or  become  candidates  for  tuberculosis.  If  they 
are  placed  in  time  under  good  hygienic  care,  their  chances  of 
becoming  strong  and  healthy  citizens  will  be  inatfr'ally  increased. 
For  children  suffering  from  pulmonary  tuber  ulo  "n  institution 
could  easily  be  annexed  to  each  of  the  largei  lihuntain  sanatoria 
for  consumptive  adults. 

From  what  has  been  said  it  is  evident  that  the  authorities  must 
soon  realize  that  something  has  to  be  done  in  the  direction  of  pro- 
viding for  the  thousands  of  tuberculous  poor — men,  women,  and 
children — of  the  large  centres  of  population. 

In  all  civilized  countries  the  agitation  for  the  creation  of  such 
institutions  is  now  most  active. 
Advocates        Dettwcilcr,^  Levden,"  and  Liebe'  have  spoken  for  Gern^any  ;  von 

of  sanatoria  >  .^  >  r  y    > 

for  the  con-  Schrottcr  '  for  Austria  ;  Grancher,'*  Letulle,®  and  Petit  ^  for  France  ; 

uniptive  )  >  )  I 

Weber,''  Lindsey,'-*  and  Walters  '"  for  England ;  Hansen  "  for  Nor- 
way;   Saugmann '"  for  Denmark;    and  in  the  United  States   we 

'  Dettweiler,  "  Mitthellungeii  iiber  die  erste  Volksheilstatte  fiir  unbemii.,  'n;  ■j^n- 
kranke  in  Falkensteiii  iin  Tiunus,"  "  Deutsclie  meil.  Wocliensclirift,"  iJi   2.    .      .,  \ 

-  Von  1-cyden,  "  Lber  die  gegenwiUtige  Behandluiig  Ttiberkuloser  und  die  st  .  \\.  un 
Fiirsorge  fiir  dieselben,"  XII.  Internationaler  Congress,  Moscow,  August  25,  1897. 

'  Liclje,  Cieorg,  "  Die  Hekiiinpfung  dor  Tiiberkulose,"  "  Deutsche  Vierteljalir^sclirift 
fiir  oiTentliclie  Ges  uidheitspllege,"  1898. 

*  Von  SchriUter,  "  Cber  den  gegenwiirtigen  Stand  der  Frage  der  Errichtung  eigener 
IleilslStten  fiir  die  Tuberkulose, "  "  Allgein.  Wiener  Med.-Zeitung,"  1892. 

°  "  Rapport  par  M.  le  Prof.  Grancher,  Seance  de  I'Academie  do  Medecine  de  Paris," 
du  3  Mai,  1S9S. 

"  Leiulle,  "  I.es  Tul)erculeiix  dans  les  Ilopitaux  de  Paris,"  "  Presse  "^T'dicale,"  1S94, 
p.  215. 

'  Petit,  L.  H.,  "  Allocution  du  Secretaire,"  IV.  Congris  de  la  I'u  ^  .  1     se,  1898. 

'  Weber,  Ilennann,  "  Croonian  Lectures  on  ttie  I  lygienic  and  t'liinaii :  i  rcalinent  of 
Chronic  Pulinonary  Phthisis,"  London,  18X5. 

°  Lii.dscy,  "  I'rolilcin  of  the  Consuni|.tive  Poor."  Inaugural  address.  "The  Lancet," 
London,  Dec.  4,  1897. 

10  Wallers,  "Sanatoria  for  Consumptive  PiUient-.,"  "The  Practitioner,"  London, 
June,  1S98. 

"Hansen,  Klaiis,  "  Forslag  lil  offentlige  Foranstallninger  mod  Tuberkulosen," 
Chrisliania,  1895. 

"  Saugniann,  Chr.,"  Sanatorier  for  lirystsyge,"  Copenhagen,  1897. 


mtmrnm 


ases,  will 
the  weak, 
atter  will, 
If  they 
hances  of 
increased, 
nstitution 
sanatoria 

ities  must 
on  of  pro- 
omen,  and 

n  of  such 

nany  ;  von 
3r  France ; 
'  for  Nor- 
Statcs   we 

L,  'ii;  Jili- 

2       .   '     .     '. 

1  die  St  .  1.1:  w 
25,  1897. 

rteljal'r«sclirift 

htung  eigcner 

2. 

ine  de  Paris," 

■dicale,"  1S94, 

se,  189S. 
c  1  realinent  of 

'riie  l.nncet," 

ler,"    London, 

'uberkiilosen," 


SANATORIA    FOR    THE   CONSUMPTIVE    POOR. 


;3i 


have  in  Bowditch,'  Hamilton,-  Biggs  and  Prudden,'  Lee,'  Tru- 
deau,-'  Flick,"  Hinsdale,^  Otis,'  Shrady,"  Rose,'"  Brush,"  Gibier,'" 
and  others,'^  strong  advocates  for  the  establishment  of  State  and 
municipal  .sanatoria  for  the  care  and  treatment  of  the  consumptive 
poor. 

The  crowned  heads  and  princes  of  Europe,  such  as  the  Czar  of 
Russia,  the  Emperor  and  the  Empress  of  Germany,  the  Emperor 
of  Austria,  the  King  of  Saxony,  the  King  of  Sweden,  the  young 
Queen  of  Holland,  the  Prince  of  Wales,  and  others,  have  placed 
the  sanatoria  for  the  consumptive  poor  under  their  high  pro- 
tection, and  have  opened  their  private  purses  most  liberally  for 
their  support.  The  nobility  and  the  aristocracy  in  finance,  art,  and 
literature  have  been  eager  to  imitate  the  admirable  example  .set  by 
their  sovereigns,  and  the  latter,  too,  have  given  freely  toward  the 
erection  and  maintenance  of  such  institutions.  Thus,  in  the 
countries  just  mentioned  a  number  of  establishments  now  flourish, 

'  Bowditch,  "  Ticatiiient  of  I'htliisis  in  S.-inatoria  near  our  Homes,"  Annual  Meet- 
inji  of  the  Mass.  Med.  Society,"  June,  1S96. 

'  1  lamilton,  "  The  I'revenliun  of  1  iil)erculusi>,"  "  Journal  of  the  Anier.  Med.  Assoc. , 
June  12,  i8()7. 

"  Biggs  and  Prudden,  Communicatiim  to  ihe  lion.  C.  ('•.  Wilson,  President  of  the 
Hoa>(l  of  Health,"  Jan.  II,  1S97,  "  .\.  V.  Med.  Journal,"  Jan.  27,  1S97. 

■*  Lee,  lienjamiii,  "  Present  .Attitude  of  Sanitarians  and  Hoards  of  Health  Toward 
Pulmonary  Consumption."  Paper  read  before  the  Section  of  State  Medicine  of  the  .Anur. 
Med    Assoc,  June  3,  1897. 

'^  Trudeau,  "Sanatoria  for  the  Treatment  of  Incipient  Tuberculosis,"  "Medical 
Record,"  Pel).  13,  1897. 

"  Klick,  "Special  Hospitals  for  the  Treatment  of  Tuberculosis,"  "Times  and 
Register,"  March  15,  1890. 

'  Hinsdale,  "  Recent  Measures  for  the  Pieventioii  and  Treatment  of  Tuberculosis," 
"  The  Medical  News,"  August,  1S94. 

"  Otis,  "  The  .Sanatorium  or  Closed  Treatment  of  I'hthisis,"  "X.  V.  Med.  journal,'' 
June  13,  1896. 

•  Shrady,  "  Medical  Record,'  vol.  I.ll,  p.  632. 

'"  Rose,  "  Gaillard's  Medical  Journal,"  New  York    18S5,  vol.  l..\. 

''Brush,  Geo.  W.,  "An  Act  to  F.stablish  a  State  Hospital  for  the  Treatment  of 
liicipient  Pidmonary  Tuberculosis."  Hill  before  the  Legislature  of  the  State  of  New 
^■ork,  1898. 

'■'Uibier,  Paul,  "Proposed  Hospital  for  Physicians  Affected  with  Tuberculosis," 
March,  1897. 

'  ■'  Mannheiiner,  "  N.  Y.  med.  Monatsschrift,  "  May,  1897  ;  Kennedy,  J.  1'.,  "  Iowa 
Health  Hullelin,"  April,  189S. 
21 


(■---■ 


322 


PULMONARY  TUBEKCULOSJS. 


1^5 


Ui 


which  are  doing  a  world  of  good  by  curing  the  curable  tuber- 
culous cases  and  taking  care  of  the  hopeless  ones,  thus  diminish- 
ing countless  centres  of  infection. 

If  a  government  is  in  earnest  in  its  endeavor  to  combat  tuber- 
culosis effectually,  besides  its  regularly  enforced  laws  against 
bovine  tuberculosis,  its  thorough  hygienic  and  prophylactic 
measures  against  tuberculosis  in  man  through  sanitary  regulations 
and  public  instruction,  it  must  take  upon  itself  the  care  and  treat- 
ment of  the  curable  and  incurable  cases  of  tuberculous  patients 
among  the  poor  and  among  those  of  limited  means.  I  mean  here, 
by  limited  means,  a  financial  condition  which  does  not  permit  a 
tuberculous  patient  to  enter  a  private  sanatorium  or  to  have  at 
home  such  medical,  hygienic,  and  dietetic  care  as  will  assure  him 
the  best  possible  chance  of  recovery. 

A  point  next  to  be  considered  would  be  how  to  recruit  the 
patients  and  how  to  discriminate  between  the  proper  and  improper 
cases,  and  thus  avoid  increasing  the  dreadful  and  degrading  abuse 
of  medical  charity,  from  which  physicians,  and  especially  the 
general  practitioners,  suffer  so  much  in  these  days. 

Just  as  there  exists  in  nearly  all  States  or  municipalities  a  com- 
mission or  a  number  of  special  examiners  for  the  purpose  of  deter- 
mining who  is  the  proper  subject  for  State  care  in  an  asylum  for 
the  insane,  so  should  there  exist  a  commission  for  the  determina- 
tion of  admission  to  a  municipal  or  State  institution  for  consump- 
tives. 

Such  a  commission,  composed  of  a  certain  number  of  general 
practitioners  and  health  officers,  should  be  aided  in  its  work  by 
the  charity  organizations.  ICach  and  every  case  should  be  investi- 
gated by  a  combined  committee  of  physicians  and  laymen  for  the 
following  purposes : 

1.  To  ilctermine  the  applicant's  condition  by  a  medical  exami- 
nation. 

2.  To  visit  his  homo  if  he  has  been  found  tuberculous,  and  to 
institute  such  hygienic  measures  as  seem  necessary  (distribution 
of  pocket-spittoons,  disinfectants,  etc.). 

3.  To  examine  the  other  members  of  the  famih'  in  order  to  find 
out  if  any  of  them  have  also  contracted  the  disease,  and,  if  so,  to 
counsel  proper  treatnient. 

4.  To  report  in  full  to  the  sanitary  authorities  concerning  the 
condition    of    the    patient's    dwelling.       Its   renovation    or  even 


PLAN    TO    SOLVK    TIIK    TUHERCULOSIS    PROBLEM. 


323 


destnictioii  may  become  imperative  when  it  is  evident  that  tuber- 
culosi.s  has  become  "  endemic  "  tiiere,  owing  to  the  condition  of 
the  seil  or  to  other  sanitary  defects. 

5.  To  determine  the  financial  condition,  whether  the  patient  is 
or  is  not  able  to  pay,  and  whether  or  not  by  his  being  taken  to  an 
institution  the  family  will  become  destitute.  If  the  latter  should 
be  the  case  it  would  become  the  duty  of  the  municipality  to  pro- 
vide for  the  family.  In  many  cases,  a  letter  of  inquiry,  sent  to  the 
former  medical  attendant  of  the  patient,  would  materially  aid  the 
work  of  the  investigation  committee. 

Any  individual  should  have  the  right  to  present  himself  for 
examination,  and  every  physician  should  be  at  liberty  to  recom- 
mend any  person  for  examination  to  the  board  of  his  precinct  or 
district. 

The  institutions  needed  to  carry  out  this  plan  would  be :  institution 

'  _  '  _  iieeileil  to 

1 .  A  centrally  located  reception  hospital  and  dispensary.    The  dis-  eireciuaiiy 
pen.sarv  should  treat  the  ambulant  tuberculous  patients,  whose  ad- '"''>''>'"■ 

ir  J  I  •  losis  III 

mission  into  the  sanatorium  is  impracticable  or  has  to  be  delayed  for'"^"- 
want  of  room.     These  dispensaries  should  also  serve  the  patient 
discharged  from  the  sanatorium  as  a  place  to  seek  counsel,  and 
thus  aid  in  his  continued  improvement  or  guard  against  approach- 
ing relapses. 

2.  One  or  several  city  sanatoria,  located  in  the  outskirts,  and,  if 
possible,  in  a  somewhat  elevated  region,  where  the  atmosphere  is 
known  to  be  pure.  Mere  ail  patients  should  pass  through  a  pre- 
paratory sojourn  before  being  sent  to  the  mountain  sanatorium. 
The  more  advanced  cases  would  all  be  retained  here. 

3.  One  or  several  mountain  sanatoria  at  no  greater  distance 
from  the  city  than  three  or  five  hours  by  rail,  at  an  altitude,  if 
possible,  of  between  one  thousand  and  two  thousand  feet,  on  porous 
ground  with  southern  exposure,  and  as  nearly  as  possible  protected 
against  the  coldest  winds,  preferably  surrounded  by  a  pine  forest. 
A  farm  in  the  vicinity,  where  the  thoroughly  convalescent  pa- 
tients can  do  light  work,  might  make  the  institution  in  a  measure 
self-supporting.  To  this  place  the  selected  incipient  and  the  im- 
proved cases  from  the  city  sanatorium  should  be  sent  to  com- 
plete their  cure.  To  the  mountain  sanatorium  there  should  also 
be  attached  a  department  for  children  suffering  frt)m  pulmonary 
tuberculosis. 

4.  Several    sea-side    sanatoria   for    the    treatment    of    children 


li 
\ 

51',. 

!  I 


»•! 


1 


■If 


.!. 


324 


PULMONARY    TUBERCULOSIS. 


Stale 
insurance 
at^aitist 
tubercu- 
losis. 


Ill 


afflicted  with  tuberculous  diseases  of  the  joints  and  other  tuber- 
culous (scrofulous)  manifestations. 

5.  A  maternity  sanatorium.  Of  the  requirements  of  such  an 
institution  I  have  already  spoken. 

By  this  plan  it  will  be  seen  that  I  am  in  favor  of  treating  tuber- 
culous patients  near  their  homes,  and  in  the  same  or  nearly  the 
same  climate  as  that  in  which  they  will  have  to  live  and  work  after 
their  restoration  to  health.  My  reasons  for  advocating  such  prin- 
ciples are  founded  on  the  experience  of  all  modern  phthisio- 
therapeutists,  who  have  demonstrated  that  the  hygienic  and  dietetic 
treatment  in  closed  establishments  is  feasible  and  successful  in 
nearly  all  climates. 

Only  by  adhering  to  these  principles  can  we  expect  to  cope  suc- 
cessfully with  tuberculosis — this  disease  of  all  climes,  but  which  is 
most  prevalent  in  large  centres  of  population,  where  civilization  has 
seemingly  attained  the  highest  standard. 

As  stated  above,  these  institutions  should  be  open  not  only  to 
the  poor,  but  also  to  those  in  moderate  circumstances  who  can  pay 
part  of  the  expense.  For  this  latter  class  of  patients,  many  of 
whom  for  reasons  of  a  noble  feeling  of  independence  hesitate  to 
accept  public  aid,  I  have  often  wondered  if  a  plan,  something  simi- 
lar to  the  State  Invalidity  Insurance  Companies  of  Germany,  could 
not  be  inaugurated  in  this  country.  There,  the  moment  an  indi- 
vidual enters  upon  the  career  of  an  ordinary  laborer  or  servant,  he 
is  obliged  to  be  insured  against  sickness,  accidents,  and  old  age. 
If  he  develops  tuberculosis  he  is  immediately  .sent  to  one  of  the 
many  sanatoria  of  that  country.  The  government  authorities,  who 
are  at  the  head  of  these  State  insurance  companies,  have  long  since 
learned  that,  through  a  timely  treatment  in  a  sanatorium,  the  tuber- 
culous individual  is  most  speedily  and  lastingly  cured,  and  conse- 
quently with  the  least  expense. 

Dr.  Weicker,  of  Goerbersdorf,  to  whose  institution  a  great  many 
of  such  patients  are  sent  by  the  government,  writes  me  that  the 
percentage  of  cures  among  these  is  higher  than  among  the  private 
patients.  His  latest  statistics  give  a  percentage  of  80  established 
cures  with  only  an  average  of  76^/  days  of  sojourn  in  the  sanatorium. 
This  marvelous  result  is  to  be  explained  by  tlie  fact  that  the 
government  insurance  ofificials  send  their  patients  to  the  sana- 
torium at  much  earlier  periods  than  the  private  physician  is  likeh- 
to  do. 


tuber- 


ich  an 


STATE    INSURANCK    AGAINST    CONSUMPTION. 


325 


Thirty-seven  of  these  government  insurance  companies  have, 
according  to  their  published  figures  for  1S97,  collectively  assisted 
44cSo  consumptives,  of  whom  4432  were  sent  to  subsidized  sana- 
toria. Nearly  all  these  State  insurance  companies  contribute  to 
the  funds  of  such  establishments;  some  have  found  it  to  their 
advantage  to  erect  special  sanatoria  of  their  own.  For  the  year 
1897  these  State  insurance  societies  of  Germany  invested  altogether 
1.300,000  marks  in  sanatoria  for  consumptives;  and  for  1898a  fund 
of  between  three  and  four  million  has  been  destined  for  that  pur- 
pose.' 

How  would  it  be  if  one  of  our  most  thickly  populated  States, 
after  having  created  a  number  of  sanatoria,  would  try  the  experi 
ment  of  a  State  tuberculosis  insurance  company  ?  How  many 
families,  even  of  the  classes  in  fair  circumstances,  but  in  which 
tuberculosis  is  dreaded  on  account  of  the  disease  having  been  the 
cause  of  the  death  of  some  of  their  members,  would  not  gladly 
avail  themselves  of  this  opportunity — especially  since  the  existing 
life-insurance  companies  refuse  apjilicants  with  a  family  history  of 
tuberculosis?  This  opportunity  offered  by  the  State  would  mean 
giving  to  their  children  the  certainty  of  being  afforded  the  best 
possible  chance  of  recovery,  should  they  be  taken  down  with  the 
family  disease.  No  matter  at  what  age,  so  long  as  the  individual 
remained  insured,  there  would  be  the  State  sanatorium  to  receive 
and  treat  him.  A  payment  of,  for  example,  fifty  cents  a  month 
from  the  birth  of  the  child  would  give  to  the  State  insurance  com- 
pany after  fifteen  years,  with  the  accrued  interest,  a  capital  of 
nearly  one  hundred  and  fifty  dollars.  By  paying  the  aggregate 
amount  up  to  the  date  of  application,  any  predisposed  individual 
might  be  insured  at  any  time,  and  such  an  institution  be  called 
into  life  at  once. 

As  has  been  stated,  the  greatest  chance  of  a  predisposed  in- 
dividual being  taken  sick  is  between  the  age  of  puberty  and 
thirty.  The  chances  of  the  disease  beconni.g  healed  without  ever 
having  been  discovered  are  between  twenty  and  twenty-five  per 
cent.  That  is  to  say,  that  out  of  every  hundred  autopsies  made 
on  people  having  died  accidentally,  or  of  diseases  other  than 
tuberculosis,  twenty  to  twenty-five  show  evidences  of  healed  tuber- 
culous lesions  (cicatrization  or  calcareous  formation).    The  chances 


f 


1 

1    ■  ■; 

!  :    ! 

S! 


'  "  IleilstilUen  Korrespondeiu,"  1898. 


326 


PULMONARY    TUI3EKCUL0SIS. 


Work  for 

l>hilaii- 

lliropists. 


of  this  disease  bein<j  cured  in  from  six  to  nine  months,  if  it  is  dis- 
covered at  an  early  period,  are  at  least  fifty  per  cent. 

The  statistical  tables  of  the  pathological  and  clinical  proofs  of  the 
curability  of  pulmonary  tuberculosis,  on  pages  32  and  329,  of  this 
work,  will  show  that  these  figures  are  correct.  It  is  not  necessary  to 
be  an  insurance  expert  to  see  that  the  State  would  hardly  be  a  great 
financial  losor  by  creating  such  an  insurance  institution.  But  the 
greatest  benefit  which  would  accrue  to  the  State  or  commonwealth 
through  such  an  enterprise  would  be  the  paving  of  the  way  toward 
a  complete  State  or  municipal  control  of  tuberculosis  among  the 
population,  which,  owing  to  their  social  conditions, could  otherwise 
not  properly  be  cared  for,  and  would  constitute  forever  an  impedi- 
ment to  the  thorough  prophylaxis  and  possible  eradication  of  the 
disease. 

To  carry  on  the  various  State  or  municipal  institutions  to  be 
erected,  with  a  view  to  effectually  .stamp  out  tuberculosis,  a  large 
staff  of  competent  physicians  would  be  needed.  These  physicians 
should  be  paid  for  their  labor.  It  is  inevitable  that  through  taking 
thousands  of  patients  into  such  institutions  the  general  practitioner 
will  lose  some  of  his  income.  Let  the  State  compensate  him  by 
paying  him  for  the  service  he  may  render  in  any  of  the  institutions 
(sanatoria,  hospitals,  or  special  dispensaries)  created  by  it  with  the 
view  of  combating  tuberculosis. 

To  proceed  with  this  work  as  soon  as  possible,  it  would  be  well 
to  transform  some  especially  favorably  located  general  hospitals 
into  special  hospitals  for  consumptives  ;  to  create  sanatoria  for 
children  on  the  sea-shore,  and  for  adults  in  mountainous  or  at  least 
in  elevated  and  healthy  regions. 

Here  is  certainly  a  large  field  in  which  our  philanthropists  can 
aid  their  State  or  municipality  in  the  speedy  erection  of  such 
institutions.  They  will  thus  not  only  help  their  unfortunate  fellow- 
men  suffering  from  consumption,  but  render  to  the  community  at 
large  an  incalculable  service  by  preventing  the  spread  of  a  disease 
to  which,  up  to  now,  rich  and  poor,  old  and  young  have  fallen 
victims  by  thousands  every  year.  Bad  food,  insufficient  cloth- 
ing, alcoholic  intemperance,  e.\cesses  of  all  kinds,  worry,  anxiety, 
etc., — all,  of  course,  favor  a  predisposition  to  consumption,  or 
hasten  the  development  of  the  disease  if  the  tuberculous  germ 
has  already  implanted  itself  in  th-  human  .system.  To  find  a 
remedy  for  these  conditions  must  be  the  work  of  the  .statesman  and 


ms 


mm 


is  dis- 


to  be 
large 


PHILANTHROPY   AND   SOCIAL    KKFORMS.  327 

social  reformer,  or  it  must  come  with  the  j^radual  advancement  of 
knowled<je  and  civilization.  One  evil,  however,  concerns  statesman 
and  sanitarian  alike.  This  is  the  ever-increasin<^  iiabit  of  cigarette- 
smoking.  It  seems  to  me,  a  law  should  be  speedily  enacted  in  all 
civilized  countries  to  suppress,  by  police  regulation,  the  smoking 
of  cigarettes  by  cninors. 

Of  the  best  means  to  overcome  a  predisposition  to  consumption, 
inherited  or  acquired,  we  have  spoken  in  the  chapter  on  Preventive 
Treatment. 


■  il 


r; 


it' 


I 


at  least 

sts  can 

3f  such 

fellow- 

nity  at 

disease 

:  fallen 

cloth- 

nxiety, 

"on,   or 

s  germ 

find  a 

an  and 

PI 


CHAPIKR  XXVI. 

CLINICAL  EVIDENCES  OF  THE    CURABILITY    OF  TUBER- 
CULOSIS  BY    THE    HYGIENIC  AND  DIETETIC 
TREATMENT. 

Conclusions. 

Since  the  disastrous  experiences  with  Koch's  first  tiiberciiline  I 
have  ceased  to  experiment  with  tubercidoiis  culture-products. 
But  while  I  have  watched  the  work  of  others  in  this  line  with  great 
interest  and  eagerness,  I  liave,  in  the  meantime,  thoroughly 
investigated  the  hygienic  and  dietetic  treatment  in  all  its  asjiects. 
A  careful  stuily  of  the  results  obtained  by  this  method  in  general, 
and  especially  in  institutions  devoted  exclusively  to  the  treatment 
of  pulmonary  diseases,  compared  with  those  thus  far  obtained  by 
the  treatment  with  any  remedy  obtained  from  culture-products, 
antitubercle  scrum,  or  medical  substances  supposed  to  act  directly 
upon  the  bacilli,  has  made  me  an  enthusiastic  advocate  for  such 
institutions,  or  for  the  same  treatment  outside  of  them  in  as  pure 
an  atmosphere  as  possible,  under  careful  guidance  of  the  ph\- 
sician. 

I  append  here  the  statistics  obtained  in  sanatoria  for  poor  as 
well  as  for  paying  patients.  I  will  first  give  an  interesting  table 
compiled  by  Mana.sse,'  covering  5032  patients  which  passed 
through  Brehr  ...m's  Sanatorium  in  Goerbersdorf,  Germany,  during 
the  years  1870-1886. 


w 


si  • 


Stagr  of  thk 

DlSEASK. 


Number  of 
Patiknts. 


ClRED. 


Almost  Curku. 


ClRFIi   ANn 
Almost  Cirko. 


1 1390(27.62%)   387(27.8  %)        430  (3'-  %)  '  817  (58 'J  7") 

II,  ....  2225(44.21%)  152(6.83%)   325(14.6%)   .177(21.43%) 

III i  I417(28-I7%)    12  (  0.48%)     m   2.3%)     45  (  3.14%) 


503* 


551  ("%) 


788(15.6%)  :  1339  (26.6%) 


'  Manasse,  "  Die  lleilung  der  I.ungentubcrkulose  in  Anstallen  itnd  Kiirorten." 

328 


iEKBRB 


I  <l 


CLINICAI-    PRODI'S    OK    THE   CUKAHILITY    OK    TUBKKCUI.OSIS.      329 

The  follovvinfj  statistics,  with  the  exception  of  the  last  six  mmi- 
bers,  wqre  collected  by  tnysclf.  Nos.  i8,  19,  ami  20  were  reported 
by  Dr.  Hcaiilavoii ; '  Nos.  21,  22,  and  23  I  have  taken  from  Hohe's 
recent  statistics.^ 


Name  of  Sanatorium. 

Repohtbo  bv 

MORTALITV. 

Curbs. 

IMPROVRD. 

Abso-       Rela- 
Intc.         live. 

1. 

l'";ilkeiisiriti,  (;ciiiiaiiy 

Dr.  Detlweiler. 

4-')5< 

14','               M'^ 

4.V'' 

J. 

llolicnhiiniit-t,  (iotinaity,  .   .    . 

"     Meissen. 

14.5:4       28  </; 

.(. 

KtippLTtsliain,  (tL'rniaiiy,  .    .    . 

"    Nahin. 

•      •      • 

U't 

77'' 

■» 

Miiskiika  C(iliu(;e  Saiiauiriniii, 

CuiKula, 

'■    Klllolt. 

I5< 

Arrested  cases. 

33''. 

.1- 

Sharon,  Mass  ,  I'.  S.  A.,  .   .    . 

"    Bowditcli. 

.     •      . 

'iH 

6. 

(»oeri)eis(t(>i  (        Saiiatuiiiini, 

Cures. 

(ioriuariy,  HreliiiiLT 

"    Acblcrmaiin. 

7-5i!< 

tsi 

50.55'< 

7, 

Croerbt'rsilt)rf       Snnatci  iiiin, 

Germany,  Kocniplei 

"    Koempler. 

rsi 

25-27'- 

s<yi 

s. 

Gnerlterstlorf        Sail  at  or  in  in, 

Ciennany,  I'liiklir 

"    Weicker. 

*i 

72:; 

9- 

KeihdIdsKiun,  Ceiniaiiy,  .    .    . 

"    Wolff. 

2.,«t 

70.72;. 

10. 

Davos,  S«  ii/erlaiicl, 

"    Tiirlian. 

4.36!» 

4(yJ 

404 

1 1. 

N(Milracli,  (ierniaiiv 

■•    Wallber. 

3<y.i 

65;< 

1  J. 

llalil.i,  I'inlanil 

"    C.abrilowitcb. 

I3-.S!< 

36.7", 

33'< 

'.V 

CaniKon,  I'taiice, 

"    Sabourin. 

Ai-»'i 

].». 

AiliroTidai  k  Cotlaye  Saiiil.iri- 

nin,  V.  S.  A 

"    Trudean. 

. 

20-25'; 

30-35!< 

I.i 

I.ooinis,  I.ilicrtx',  N.  \'.,     .    .    . 

"    SUibliert. 

•      *       • 

2Vf 

50^' 

16. 

Clicstiinl  Hill,  Pa 

"    Colien  ami  Ba- 
con. 

I7.33"< 

s. 

T..5* 

17. 

Winyali,  Aslieville,  N.  C,    .    . 

"    von  Ruck. 

A-i 

26.64-^ 

42.47'; 

IS. 

I.eysiii,  Swilzeilaml 

"     Burnier. 

jy.n 

11-3^ 

i».r:i 

"9. 

ReiihnrR,  (".LTiiiaiiv 

"    'rhornspeckeii. 

2W 

4ffr 

3?' 

■JO. 

Vciilnor,  I'.iiKlaiui 

'•    CoKliill. 

S.?.'' 

Much 

improved. 

164'; 

Improved. 

654* 

21. 

Hanfe  Sanatorinni,  St.  Blasieii, 

"    Sander. 

i7:i 

f>7'-r 

22. 

ScliomherK,  (ifiinanx' 

"    Baudacli. 

Sz.iyi 

13- 

Malchow  b.  Berlin,  Germany, 

"    Renter. 

'43^ 

AoH 

I , 


1  will  adtl  that  the  sanatoria  at  Ruppe^rtshain,  Malchow,  Chest- 
nut Hill,  and  Ilalila  are  for  the  poor.  In  the  Adirondack  Sani- 
tariinn,  Loomis,  Sharon,  Muskoka,  and  at  Ventnor  the  patients 
pay  part  of  the  expense.  At  the  Adirondacks,  Rnppertshain,  and 
Muskoka  sanatoria  they  do  not,  as  a  rule,  admit  advanced  cases. 
At  the  Chestnut  Hill  Hospital  for  Consumptives  (Philadelphia)  all 
cases,  no  matter  how  far  advanced,  are  received.  To  distinguish 
between  the  terms  absolute  and  relative  cure,  I  will  give  Dett- 
weiler's  definition.  He  calls  absolutely  cured  the  re-establishment 
of  the  normal  functions  of  all  the  organs  and  the  complete  dis- 


1  Deaulavon,  "  Contributions  a  retiule  du  traitement  de  la  tuberculose  inilinonaire," 
etc.,  "  Thdse  de  Paris,"  1896. 

2  Holie,   "Die   liek.iinpfung    und    Ileilung  der  I.ungenschwindsnrht,"   etc.,    Miiii- 
clien,  1897. 


(Iff 


330 


PUI.MONAKY    TUUKRCULOSIS. 


appearance  of  the  bacillus.  He  culls  a  person  relatively  cured 
when  his  general  well-beinj;  has  reapjicared  in  spite  of  regular 
coughinjj  spells  with  some  expectoration  in  the  morninj^r. 

We  may  ask  how  long  tiiese  reported  cures  have  lasted. 
Among  99  patients  discharged  from  Falkenstein  as  cured 
72  were  alive  and  well  at  the  time  the  inquiry  was  made,  when 
the  patients  !iad  left  the  sanatorium  from  tliree  to  nine  years. 
In  15  cases  a  relapse  had  occurred,  but  12  of  these  had  im- 
proved again;  12  had  died.'  Dr.  von  Ruck,  of  Asheville,  re- 
ported to  me  that  he  had  written  to  605  of  his  f  ner  patients  who 
had  left  the  sanatorium  from  one  to  three  y  Sefore ;  457  re- 

sponded, directly  or  through  friends.  Of  the  ,  felt  absolutely 
cured;  70  felt  relatively  cured ;  258  felt  still  improved;  62  got 
worse  or  had  died. 

Dr.  E.  R.  Baldwin,  of  Saranac  Lake,  reported  at  a  recent  meet- 
ing of  the  American  Climatological  Association,-  that  at  the 
Adiron(]ack  Cottage  Sanitarium  they  were  in  constant  correspond- 
ence with  115  patients  who  had  been  discharged  in  the  last  ten 
or  twelve  years  ;  and  while  a  few  had  relapsed  slightly,  the  majority 
of  them  were  well  and  at  their  homes. 

The  results  of  all  the  curative  treatments  speak  in  favor  of  the 
hygienic  and  dietetic  treatment  under  strict  medical  supervision; 
and,  regarding  prophylaxis,  no  measures  have  yet  proved  of  any 
value  except  good  sanitary  laws,  rigorously  enforced,  regarding 
the  prevention  of  tuberculosis  in  man  and  beast,  and  the  creation 
of  sanatoria  and  special  hospitals  for  the  treatment,  especially  of 
the  consumptive  poor. 

In  the  preceding  chapter,  on  the  Social  Problem  pf  Tuberculosis, 
I  believe  to  have  sufficiently  demonstrated  that  in  the  end  the 
commonwealth  would  be  the  financial  gainer,  even  if  the  large 
stiff  of  physicians  necessary  for  such  institutions  would  receive 
a  just  retribution  for  their  labors,  which  are  most  arduous  in 
establishments  where  the  constant  medical  supervision  consti- 
tutes one  of  the  most  essential  parts  of  the  treatment.  When 
the  worthy  but  poor  consumptive  is  taken  in  time  to  an  insti- 
tution where  liis  chances  of  recovery  are  still  good,  he  will  not 


'  Deltwcilcr,  "  liericht  iiber  72  scit  3-9  Jaliren  in   FalUensteiii  vijllig  geheilte  I'allc 
von  T.ungenschwiiulsuclit,"   l88t). 

2  "New  Yi'iU  Medical  Record,"  vol.  I.\',  No.  I9. 


/ 


I 


CONSUMPTION    A   SOCIAL    DISEASK. 


331 


cured 
if^nilar 


62  got 


Ii.ivc  a  chance  to  infect  tlie  otiier  members  of  tlie  family,  and 
he  is  h'kely  to  return,  after  a  relatively  short  sojourn,  restored  to 
lu-alth  and  liy^ienically  educated,  ready  to  betomc  a^ain  the  bread- 
winner of  his  family.  Now,  as  aheady  shown,  tlie  maintenance  of 
this  i)atient  in  a  municipal  sanatorium  for  from  three  to  six  months 
or  even  longer,  during  the  earlier  sta^e  of  the  liisease,  will  cost  the 
commonwealth  no  more  than  if  he  had  been  taken  to  the  general 
hospital  for  perhaps  the  same  period  of  time,  but  in  a  much  farther 
advanced  and  more  hopeless  state  of  his  disease. 

Even  the  family  will  be  C'  onomically  benefited  by  the  removal 
of  the  consumptive  to  whose  care  much  time  and  expense  had  to  be 
devoted.  How  often  does  it  not  hapi)en  that,  owing  to  the  chronic 
sickness  of  one  member  of  the  family,  another  or  sometimes  two 
are  hampered  in  their  wage-earning  capacity? 

As  has  been  shown  on  page  312,  the  daily  expense  of  a  patient 
in  a  plainly  but  well-equipped  sanatorium  for  consumptives  is 
little,  if  any,  higher  than  the  cost  per  day  of  a  patient  in  a  general 
hospital.  If  the  family  were  absolutely  destitute,  the  other  mem- 
bers would  have  to  be  supported  by  the  municipality,  whether  the 
head  of  the  family  were  in  a  sanatorium  or  general  hospital.  But 
since,  when  treated  in  time  and  in  a  special  institution,  he  has  from 
twenty-five  to  thirty-five  per  cent,  more  chances  of  getting  well, 
the  likelihood  of  the  community  being  obliged  to  support  a  widow 
and  several  orphans  has  thus  also  been  reduced  by  nearly  one- 
third. 

Consumption  is  a  social  disease,  and  society  must  help  the 
medical  profession  to  cure  it,  not  only  in  the  rich,  but  also  in  the 
poor  and  poorest  classes.  The  plan  on  which  the  second  German 
.sanatorium  for  consumptives  was  built  shoidd  serve  practical 
philanthropists  as  a  model  enterprise  worthy  of  emulation.  Some 
twenty-odd  years  ago  a  few  wealthy  citizens  of  the  city  of  Frank- 
fort-on-the-Main  united  with  some  of  the  leading  physicians  of  that 
city  to  open  a  sanatorium  for  the  wealthier  class  of  consumptives. 
They  pledged  themselves  to  accept  no  more  than  five  per  cent, 
on  the  invested  capital,  the  annual  surplus,  after  repairs  and 
improvements  had  been  made,  to  go  toward  the  erection  of  a 
sanatorium  for  the  poor.  Thanks  to  this  and  some  additional 
donations  there  is  to-day,  at  Ruppertshain,  near  Falkenstein,  one 
of  the  most  nourishing  sanatoria  for  the  poor. 

But,  I  repeat,  we  not  only  need  sanatoria  supported  by  private 


L   li 


m^ 


332 


PULMONARY   TUBERCULOSIS. 


beneficence,  but  also  such  as  ar°  in  part  or  entirely  maintained  by 
tile  State  or  commonwealth,  where  the  poor  or  those  able  to  pay  a 
moderate  price  can  receive  the  best  care  modern  phthisio-therapy 
can  bestow  upon  them. 

In  the  issue  of  October  30,  1897,  the  venerable  editor  of  the 
"  Medical  Record,"  Dr.  Shrady,^  referring  to  the  papers  on  tuber- 
culosis read  at  the  recent  International  Medical  Congress  at 
Moscow,  recommends  the  establishment  of  special  institutions  in 
the  United  States  for  the  treatment  of  pulmonary  tuberculosis. 
This  method  of  treatment,  the  discussion  at  the  Congress  showed, 
had  met  with  so  large  a  measure  of  success  abroad.  Concluding 
his  excellent  'editorial,  Dr.  Shrady  says:  "The  rational  method  of 
treating  tuberculosis  is,  without  doubt,  for  the  sufferer  to  live  under 
those  conditions  which  fulfill,  in  the  highest  possible  degree,  the 
laws  of  hygiene  and  diet."  What  has  been  said  on  the  subject  of 
the  treatment  in  these  pages  will  show  how  thoroughly  I  am  con- 
vinced of  the  truth  of  this  statement. 

If  we  wage  a  vigorous  war  on  all  that  is  unsanitary  in  our  cities, 
towns,  and  villages  ;  if  we  endeavor  to  raise  the  coming  generation 
to  be  a  strong  people,  able  to  resist  the  invasion  of  the  pathogenic 
micro-organism  which  may  escape  the  watchful  eye  of  the  sani- 
tarian ;  if  we  can,  by  the  creation  c^  s.inatoria  for  all  classes,  rich 
and  poor,  and  by  carrying  out  the  hygienic,  dietetic,  educational, 
and  symptomatic  treatment  for  all  consumptives  outside  of  such 
institutions,  cure  the  curable  and  make  harmless  the  incurable 
tuberculous  patients,  the  problem  of  dealing  with  the  most  widely 
spread  of  all  diseases  will  have  been  solved. 

What  is  needed  to  attain  this  end  is  the  united  working  of  the 
statesman,  philanthropist,  sanitarian,  physician,  and  the  good-will 
of  an  intelligent  people  ;  for,  as  the  immortal  Pasteur  has  said,  "It 
is  tJi  t/ic  ptnver  of  111(111  to  cause  all  parasitic  diseases  to  disappear  from 
the  world." 


'  "  \ew  York  Meilicnl  Record,"  vol.  i  u,  p.  6^2. 


tained  by 
e  to  pay  a 

io-tlierapy 

tor  of  the 

on  tuber- 

ij^ress    at 

tntions  in 

Derculosis. 

s  showed, 

oncliiding 

method  of 

live  under 

iegree,  the 

subject  of 

I  am  con- 

our  cities, 
Igeneration 
pathogenic 
\(  the  sani- 
lasses,  rich 
ducational, 
ie  of  such 

incurable 
ost  widely 

ing  cf  the 

good-will 

IS  said,  "/( 

ppear  from 


?f 


H 


INDEX 


A. 

Acid,  I'yroligncous,  45 

AdiroiulacU  Cottage  Sanitarinin,  159 

Advocates  of  sanatoria  for  tlu;  consumptive 
poor,  320 

AerotliLrapy  in  laryngeal  tuberculosis,  269 
in  sanatoria,  2I_^ 
in  tlie  treatment  of  fever,  259 
rest  cure  and  exercise,  213 

After-treatment  of  hemoptysis,  257 

Air  l)atlis  for  children,  82 

Alabama,  OS 

Albertsberj;,  Sanatorium  of.  III 

Alcohol  in  the  dietetic  trealnunt,  241 

preilispo>ing  10  tuberculoNis,  6; 

Alland,  Sanatorium  of,  12S 

Altitudes,  1  li^h,  20t 

Intermediate,  201 
Ordinary,  205 

Ambler,  Dr.,  on  the  use  of  tuberculin, 
268 

An\bulant  patients,  Instructions  for,  29S 

Andral,  Dr.,  on  the  cura'nility  of  pulmo- 
nary tuijerculosis,  31 

Andvord,  I  )r. ,  on  the  rest  cure  at  low  tem- 
peratures, 213 

Anorexia,  244 

Antipyretics,  261 

Antistreptococcic  serum,  262 

Arabic  school  on  the  conlagiousnei-s  ar  d 
curability  of  pulmonary  tuberculosis. 
18 

Aretaus  on  the  management  of  phthisical 
patients,  18 

Arkansas,  68 

Arid  air  of  private  dwellings,  88 

Arnozan,   I'rofessor,  on   revuUion,  253 

AroMi,  .Sanatorium  ol,  1 23 

Artificial  pine  forests,  2<)4,  306 

Asheville  Sanatorium,  174 

Atkins,  Dr.,  on  the  spread  of  tuberculosis 
in  health  resorts,  37 

Atropine  in  pulmonary  hemorrhage.  255 

Auto-infection,  ('utane<uis  lulierculosis  liv, 

5'     . 

Autopsies,  Danger  in  performing,  51 

Average  tegime,  23S 

Aviccnna  on  mountain  climates  and  the 
curability  of  tuberculosis,  iS 


B. 

Bacilli,  Destruction  of,  44 

Disseinination  of,  through  sputum, 

.  36  . 
I'avorite  abiding  ])lace  of,  in  eiiil- 

dren  and  adults,  49 
in  cigars,  47 
Ingestion  of,  46 
Inhalation  of,  35 
Inoculation  of,  5  I 
\umlicr  of,  expectorated  in  twen- 
ty-four hours,  35 
Bacillus  tubercidosis,  Koch's  discovery  of 

tlie,  35 
Bactericidal  (puilities  ol    nasal   mucous  .se- 
cretions, 36 
Bacterio medicinal  treatment  of  fever,  262 
Bakeries,  I'recautions  to  be  taken  in,  50 
Baldwin,  Dr.  E.  R.,  on  infection  from  the 
hands    in     inilino- 
nary  phthisis,  47 
on    the    duration    of 
cures    effected    in 
sanatoria,  330 
Baliestre,  Dr.,  on  the  sjiread  of  tul)erculosis 

in  liealth  resorts,  37 
Barnes,  Dr.,  llumidilier  of,  304 
Baruch's  douche  apparatus,  22() 
Baudel  on   the  pathological  proofs  of  the 
curability  of  pulmonary  tubercidosis,  32 
Beaconslield,  Lord,  on  pure  air,  87 
I'xard,  Care  of,  46 

Beaux  on  i)atliological  proofs  of  the  cura- 
bility of  pulmonary  tuberculosis,  32 
Bed-linen,  tare  of,  47 
Beef  essence,  240 

Preparation  of  raw,  23() 
I'ennet  on  ]iatliological  proofs  of  the  cura- 
bility of  pulmonary  tuberculosis, 

on    the    treatment   ot    plnhisis    by 
hygiene  and  fresli  air,  25 
Berck-sur  Mer,  Maritime  hospital  of,  III) 
I'lernnngham,    Dr.    K.  J.,  on    results  with 

antistreptococcic  serum,  263 
Bible  kissing  in  court.  Danger  of,  4S 
Bichloride  of  mercury  a>  di>infectanl,  44 
Bicycle,  201 
Bier's  treatment  of  joint  tuberculosis,  274 


•i 


I 


333 


334 

liiggs,   Prof.    Hcrm.    M. 


INDEX. 


Hi: 


ifc'.su^s- 1         \:f\ 

IP'    i! 
lis     f 


on  patliological 
proofs  of  the 
curability  o  f 
])u  1  mo  nary 
tul>erculosi^, 

report  sliowing 
tlic  (lecre;ihe 
in  llie  (leath- 
ratc  from  tu- 
bercular dis- 
eases in  New 
York  Ci  ty, 

317 

Ulootl  enetnata,  249 

Hlooil-letting  in  phthisis  puhnonalis,  21 

lilumenfeld,  J)r.  Felix,  on  meteorological 
inlluence  in  phthisical  patients,  205 

liodington's.  Dr.  <  ieorgc,  early  efforts  in 
sanatorium  treatment,  2^ 

Uoerhar.ve  on  change  of  localities  for 
jihthisical  patients,  19 

Bolliiiger,  Professor,  on  pathological  proofs 
of  the  curability  of  pulmonary  tubercu- 
losis, 32 

Koston  Free  Home  for  Consumptives,  169 

Houcliaril,  Professor,  on  the  curability  of 
pulmonary  tuberculosis,  33 

Houdet  on  pathological  proofs  of  the  cura- 
bility of  pulmonary  tuberculosis,  32 

Bovine  tuberculosis,  66 

J5owditch,  Dr.  Vincent  V.,  01^  the  need  of 
sanatoria  near  our  homes,  320 

I'rcathing-chair,  Usedom's,  2l6 

Breathing  exercises,  description  of,  82 
in  s<lio<>l,  .S6 
of  pregnant  women,  Si 

Brehmer,  Dr.  Hermann,  24 

Hrehmer's  Sanaloriiun,  96 

Bromplon  Hospital,  133 

Broncliilis,  270 

Broncliorrhcea,  252 

lirnoklyn    Home  for  Consumptives,   181 

Brouanlcl,  Prof. ,  on  infection  through  vac- 
cination, 52 
on  |)athological  proofs  of 
the  curability  of  pnl- 
ni'inary    lulKiculo>is, 

M 
Broussais'  theory  of  inllainmalioii,  21 
Brush,    Dr.,  on  the    need  of   State  inslilu- 

tions  for  the  consumptive  poor,  321 
Bugge,  Dr. ,  on  the  pathological   proofs  of 

the  curability  of  pidmonary  tuberculo.-is. 

Buildings  for  special  hospilals,  294 
Bureau  of  .Xninial  Industry,  /4 

C. 

Cadeac,  Dr.,  on  the  virulence  of  tubercu- 
lous products.  40 


Calcareous  foci,  Dejerine's  investigation  of 

old,  34 
Calcareous  transformation  of  tubercles,  34 
California,  69 

Canigou,  .Sanatorium  of,  1 16 
Carbolic  acid  as  disinfectant,  44 
Care  of  room,  bed-linen,  etc.,  47 

of  teeth,  241 
Carrera,     Dr.,    on    tuberculous    infection 

through  sexual  relation,  32 
Carswell,    Dr.,  on   jiathological    ])roofs  of 

the  curability  of  pulmonary  tuberculosis, 

31 

Catarrhs,  Susceptibility  to,  80 
Cattle,  F^xamination  of  imported,  76 
Cauldwell  s.  Dr.  Charles  M.,  report  of  St. 

Joseph  Hospital,  312 
Causes,  Social,  [jredisposing  to  tuberculosis, 

63 
Cels\is   on   the    .selection    of    climate  for 

consumptives,  18 
Central     bureau.    Work  of   a,    to  combat 

bovine  tuberculosis,  74 
Cervcllo's  treatment  by  "  formalina,"  288 
Charcot,   Professor,  on    the   curability    of 

tuberculosis,  32 
Chauveau,  Professor,  on  the  infectiousness 

of  tuberculosis,  22 
Chestnut  Hdl  Hospital  for  Diseases  of  the 

I.ungs,  162 
Ciliary,  Professor,  on  ])athological  proofs  of 

the  curability  of  pulmonary  tuberculosis, 

32 

Childbirth,  282 

(  liildren, Tuberculous,  in  public  schools,  60 

t  hills,  264 

Chloride  of  sodium  and  intense  minerali.:a- 

tion,  247 
Cigars,  Hacilli  in,  47 
Circulars  for  public  instruction,  57 

of  the   Pcniisylvania  Society  for 
the  Prevention  of  Tuberculosis, 

....    59 

Circumcision,  Danger  of  tuberculosis  from 
iilnal,  53 
Ritual — how  it  may  be  per- 
formed with  safety,  54 
t'itric  acid  to  prevent  coagulalimi,  44 
Clarke,    Dr.,  on   the    inoculability  of  lud- 

monary  tuberculosis,  22 
Cli'.wiing  of  spittoons,  44 
Climate,  Choice  cil  warm  and  colil,  202 

Weber's  classification  of,  201 
Climatic  idiosymrasies,  202 
Climate)  therapy    in    the  treatmiiit  of  pul- 

moiniry  tuberculosis,  2co 
Coal-smoke  nuisance,  64 
Coals.  Dr  ,  on   pathological   proofs  of  the 
curability  of  pulmonary  tuberculosis,  J2 
Cod-liver  oil,  245 

Cohnhcim    on    the    inoculability   of    pul 
monarv  tuberculosis,  22 


inrection 


INDEX. 


335 


Collins  and   Murray's  case  of  tuberculosis 

through  tattoojjig,  54 
Colorado,  69 

Coinmunicahility  of  pulinouary  tuberculo- 
sis 35 . 
Communion   cup,    ("oinmon,  cause   of  the 

propagation  of  tlisea.scs,  48 
Compensation   for    destroyed    tuberculous 

tattle,  76 
Conclusions,  328 
Connectici.i,  69 
Constipation,  25 1 

Consumptives  in  health  n-sorts,  290 
Contagious  nature  of  tuberculosis,  I'opular 

belief  in  the,  20 
Cornet,  Dr.,  on  the  danger  of  careless  and 
promiscuous  expectorating, 
36 
on    the    inoculability   of  pul- 
monary tuberculosis,  22 
Cornil,  Professor,  on  the  cuialiilily  of  pul- 
monary    tuberculol-. 

32 
on    the    inoculability   of 
pulmonar^    Mibcreulu 
sis,  22 

Cough,  251 

Counter-irritants,  253 

Craigleith  Hospital,  136 

Creosolal,  246 

Creosote,  246 

Cullen's,  of  F.dinhurgh,  singular  o])inion 
on  the  contagious  nature  of  lujjerculosis, 
21 

Culture  products,  2cSt) 

(Juraliilily  of  |)ulmonary  tuberculosis,  Path- 
ological procifsof  the,  31-34 

Curchot  and  (  arriere  on  buttermilk  and 
grapes  as  diet,  22 

Cure,    Duration  of,  obtained   in  home  eli 
males,  20? 

Cure<l  patients,  285 

Curveilhieron  tlie  curabililv  of  iHberculosis, 

Cutaneous  system.  I'.ducation  ot  the,  to 
a|)plitatioii  of  cold  water,  87,  226 

D. 

Danger  in  liealih  rt'sorls,  37 

in  perfcirniiiig  autopsies,  51 

in  swallowing  expectoration,  46 

of  cuspidors  placed  on  the  ground, 

38 
of    long  trailing  street    dresses  to 

the  public  health,  ()2 
of  remaining  too   long  in  reclined 

position,  214 
of   Inliereulosis  through  lilual  cir 

cumcision,  53 
lo    patients   suHtring    from     acute 

diseases,  310 


Daremberg  on   the  administration  'if  anli- 

pyrelics,  261 
Davos  sanatorium  of  Dr.    Tmban,  120 
Death  rale   from   tuberculosis   in  England 

and  Wales,  307 
Debove's  meal  jiowder,  250 
Deep   breathing,  Value    of,    in    the    after- 
treatment  of  hemopty.sis,  257 
Dejerine's  investigation   of  old  calcareous 

foci,  34 
Delaware,  69 

Description  of  an  ideal  sanatorium,  204 
Destruction  of  tuberculous  meat,  76 
Dettweiler,   Dr.   P.,  on   coughing  without 
cause,  251 
on  the  influence  of  the 
wealher     on     con- 
sumptives, 205 
on  the   need  of  sana- 
toria  for   th>.'    con- 
sumptive poor,  320 


on  the  rest  cure,  25 


on     the    duration    of 
cures    obtained    in 
sanatoria,  330 
Dettvvi  iler's  "  Hustenflaschchen,"  42 
Diabetes,  273 
Dianhiea,   250 

Diet  in  laryngeal  tuberculo-is,  26S 
I  iietelic  treatment  of  fever,  2t)0 

ol  |julmonary  tuberculo- 
N  237 
Dilalaiion  ;.!  the  stoui.u  h,  250 
Directions  fo?  inspeclini;  hei  Is,  Prof.  Pear- 
son's, 74 
Discipline,  2/'; 

Discovery,  K'        ^,  of  the  bacillus  tuber- 
culosis, 35 
Diseases,  Phthj^jo  gencsic,  88 
Di^  nfectant,  liiehlnride  of  mercury  as,  for 
tubercuWius  secretions,  44 
Carb'ilic        i  as.  for  tubercu- 
lous       I  el  ions,  44 
Viixx.  .  iiicgar  as,  fortuliercu- 
Iiui>.  secretions,  45 
Disinfection  free  to  the  poor,  58 

of  railway  cars,  The   need  of 

regular,  60 
of  spoons,  knives,  etc.,  21 1 
of  stools   in   intC'tinal   tuber- 
culosis, 51 
of  theatres,   churches,    inu^ic 

halls,  etc.,  61 
with  formaldehyde,  58 
Dispensary  patients,  297 
Disposnl  of  the  tuberculou>  dead.  <>2 
Dissemination  iif  bacilli   through  sputum. 

Distribution,    (ieographical,  ot    bovine   In 

berculosis,  Gy 
District  of  Columbia,  6i) 
Domestic  pels,   Tuberculosis  in,  50 


i'l 


:m^n 


336 


INDEX. 


Iff, 


^i0^      i 


Oouclie  appaialiis,  Improvised,  2J2 
Douche  rouiii,  AiT.\ii{;emeiu  of,  226 
DiOhS   for  liolli   sexes,  lieiieral   rules  coii- 

cerniiif,',  234 
Dress  reform,  jeniiess-Miller  system  of,  255 
Dresses,   Loiij;  trailing,    a  danger  to    tlie 

|mblic  health,  62 
Dry   tuberculous   sputum   a  propagator  of 

disease,  36 
Dupre   de    Lisle    on   horseback   riding    in 

consumption,  20 
Duration  of   cure   obtained    in   home    cli- 
mates, 206 
of  cure  obtained  in  sanatoria,  330 
Dyspna-a,  264 

B. 

Earthworm  a  propagator  of  tuberculosis,  51 

Eaters,  Horn  l)a<l,  SiS 

Economic  and  social  gain  by  timely  tieat 

ment  in  sanatoria,  314 
Education   of  the  cutaneous  and  nervous 

systems  to  the  a|)plication  of  cold  water, 

87, 226 
Education  of  the  phthisio-llierapeutist,  2S4 
Educational  treatment,  277 
Educators,  Sanatoria  as,  310 
Emphysenui,  264 
B^inpyema,  271 
Entrance  of  the  bacillus  itito  the  lunnan 

system,  35 
Etiology  of  inl)(  rcuUwis,   Dr.    von     Ruck 

on  the,  67 
Examination  of  [  clients,  280 
Exercise   during    n:   application   of    coUl 

water,  J 26 
F.xercise  fur  patients  in  the  habit  of  stoo|i- 

nig,  84 
Exercise,  Respiratory,  82,  214 

Walking,  2 17 
Expectoration,  Danger  in  swallowing  the, 

46 
Expense  in  American  sanatoria,  312 
Experiments  of  Hiigge  aiul  Eat^clunko,  43 
Extreme  state  of  wi-akniss,  2t)4 


Falkenstein,  Sanalorimn  of,  90 

Eallo|ipio  on  the  choice  of  climai  •  in  con 
sumption,  18 

Fever,  liacterio-medicinal  trcalimiit  of,  262 
Dietetic  treatment  of,  .  "o 
in  general,  258 
Medicinal  treatment  of,  2()l, 
Physical  means  to  comii.u,  259 
Prophylactic  IreatuienI  of,  259 

Fibrinous  transformation  of  tubercles,  34 

Finkler,  Professor,  on   the  value  of  tropoii 
as  food  in  phthisis,  241 

Fire  precautions  in  a  sanatorium,  209 


Fistula  in  ano,  276 

Flick,  Ur.  Lawrence,  on  special  hospitals 
for  the  treatment 
of  tuberculosis,  32 1 
on  the  use  of  iodo- 
form   in    phthisis, 

245 
Hies,  Transmission  of  bacilli  through,  40 
Flint  on  the  pathological  proofs  of  the  cura- 
bility of  [luhnonary  tuberculosis,  32 
Florida,  73 
Fliigge,  Professor,  on  the  infectiousness  of 

sahva,  43,  55 
Footwear,  236 

lormaldehyde,  Disinfection  with,  58 
Fowler,  Dr.,  on  the  pathological  proofs  of 
the  curability  of  pulmonary  tuberculosis, 
32 
I'ox,  Dr.   Wilson,  on  the  inoculal)ility  of 

tuberculosis,  22 

iraenkel's,  Professor  15.,  mouth-mask,  44 

on  the  durability 

of     cures      in 

home  climates, 

203 

Preudenthal,  Dr.,  on  the  infectiousness  of 

saliva,  46 
Fiirbringer,      Professor,     on     pathological 
proofs    of   the    curability  of  pulmonary 
tuberculosis,  32 


Q. 

Gabriels,  .'>anitarium,  I47 

Galen  on  the  contagious  nature  of  tubercu- 
losis and  its  treatment  by  high  altitudes, 
18 

Galtier's,  Dr.,  experiments  of  freezing  and 
thawing  tuberculous  sputum,  40 

Cjeneral  hospital.  Sojourn  in,  309 

medicinal  treatment  of  fever,  261 

Georgia,  69 

Geihardt,  Professor,  on  the  <hirahility  of 
cures  in  home  climates,  203 

Gibier,  Dr.  Paid,  on  the  tieed  of  special  in- 
stitutions for  the  consumptive  poor,  321 

tiihon.  Dr.,  on  the  danger  of  bicycling  in 
tuberculosis,  2()I 

CJirdiier,  Dr.  John  IL,  on  bovine  tubercu- 
losis in  North  Caro  ina,  71 

Gleitsmann  on  surgical  intervention  in 
laryngeal  tuberculosis,  2()9 

Glockner  Sanitarium,  180 

Goerbersdorf,  96 

•  irancher,  Professor,  on  necro  tulierculosis, 

47 

on  the  curability  of 
pulmonary  tubercu- 
losis, 32 

on  the  inocidabilily  of 
tuberculosis,  22 


i  I 


INDEX. 


337 


Grancher,  Professor,  on  the  need  of  special 
institutions  for  the  consumptive  poor, 
320 

(^uaiacol,  247 


H. 

Hamilton,  Dr.,  on  the  need  of  special  in- 
stitutions for  the  consumptive  poor,  321 
Hance,  Dr.,  on  the  infectiousness  of  dust, 

36 
Hansen,  Dr.  Klaus,  on  the  need  of  special 

institutions  for  the  consumptive  poor,  320 
Harris,  Dr.,  on  the  pathological  proof  of 

the  curability  of  pulmonary  tuberculosis, 

32 

Hauflc's  sanatorium  at  St.  Blasien,  112 

llaushalter.  Dr.,  on  the  dissemination  of 
bacilli  through  flies,  40 

Headwear  for  men,  235 

Health  ordinances,  59 

resorts.  Consumptives  in,  290 
Danger  in,  37,292 

"  Heilsiaiten-Korresixmdenz,"  26 

Heitler,  Professor,  on  pathological  proofs 
of  the  curaliility  of  pulmonary  tuberculo- 
sis, 32 

Hemophilic  diathesis,  258 

Hemoptysis,  254 

Hemorrhage,  Suggestive  treatment  of  i>ul- 
monary,  255 

Herard,  Dr.,  on  the  inoculubility  of  pulmo- 
nary tul)erculosis,  22 
on    the   curability  of  pulmo- 
nary tuberculosis,  32 

Hinsdale,  Dr.,  on  ihe  need  of  special 
institutions  for  the  consumptive  poor, 
321 

Hippocrates  on  the  curability  of  tubercu- 
losis through  rest  and  exercise,  17 

History  of  tuberculosis,  Interesting  data  in 
the,  17 

Hitchcock,  Dr.  W.  W.,  on  the  lack  of 
(ihysical  development  in  children,  86 

Hodenpyl,  Dr.,  on  the  action  of  dead 
bacteria,  47 

Hoffa's  treatment  of  local  tuberculous  pro- 
cesses, 275 

Hoffmann,  Dr.  Friedrich,  on  moist  atmos- 
phere, 19 

Hoheiihonnef,  Sanatorium  of,  105 

Holy  water  may  transmit  disease,  |8 

Home  climate,  203 

Home,  The,  at  Denver,  177 

Homes,  Treatment  of  consumptives  at 
their,  302 

Hufland  on  the  hereditary  influence  of 
tuberculosis,  21 

Humidifier  of  Dr.  liarnes,  304 

Hurty,  Dr.  J.  N.,  oti  the  tuberculous-milk 
problem,  77 


llydrotherapeuticsin  the  general  treatment 
of  pulmonary  tuber- 
culosis, 226 
to  strengthen   a  predis- 
posed individual,  87 
Hydrotherapy  in  the  treatment  of  fever,  259 
Hygeia,The,  175 

Hygiene  in  laryngeal  tuberculosis,  286 
of  room,  47 

Personal,  and  dress,  234 
Hyperhidrosis,  254 


I. 

Ichthyol,  246 
Idaho,  69 

Ideal  sanatoriimi.  Description  of  an,  204 
Illinois,  69 

Immigration  of  tuberculous  patients.  Legis- 
lative restriction  of,  292 
Impermeal)le  pocket  lining,  45 
Imported  cattle,  Examination  of,  76 
Indiana,  69 
Individual    predisposed     to    tuberculosis. 

Description  of  an,  80 
Infection  by  ingestion  of  bacilli,  46 
by  inhalation  of  bacilli,  35 
by  inoculation  of  bacilli,  51 
from   the    hands   in    pulmonary 

phthisis,  47 
from  wet-nurse  to  child,  and  Tiff 

vcrs<7,   52 
through  sexual  relations,  52 
Tuberculous,  of  animals  through 
man,  209 
through  tattooing, 

54 
through     vaccina- 
tion, 52 
Infectious  property  of  bacilli  retained  after 

burial,  62 
Influence  of  the  weather  on  consumptives, 

lilumenfeld  on  the,  205 
Ingals  on  choice  of  warm  or  cold  climates, 

201 
Ingestion  of  bacilli,  46 
Inhalation  of  bacilli,  35 
Injustice  to  States  with  good  bovine  laws, 

73 
Inoculation,  Infection  by,  51 
Insomnia,  266 
Inspection  of  cattle,  74 
Instruction,  Circulars  for  public,  57 
Institutions,    Special,  for  the  consumptive 

(lOOr,   320 

Supervision  of  public,  57 
Instruction  for  ambulant  patients,  298 
Insurance,  Slate,  against  tuberculosis,  324 
Intense  mineralization,  Chloride  of  sodium 

and,  247 
Intercostal  neuralgia,  253 


'I 


m 


I 


338 


INDEX. 


Intercurrent  diseases,  268 
Intestinal  tuberculosis  in  adults,  250 
in  children,  49 
Iodoform,  245 
Iowa,  69 

Isocrates  on  the  contagiousness  of  tubercu- 
losis, 17 
Isolation,  Pavilion  for,  208 
Value  of,  317 


J- 

Jiiccoud,  I'rof.,  on  the  curability  of  tuber- 
culosis, 32 
Jacobi,  Prof   A.,  on  tuberculous  infection 
through    ritual      cir- 
cumcision, 53 
on  the  administration  of 
digitalis   in   pneumo- 
nia, 272 
Janeway,   Prof    K.   G.,  on  milk  diet    in 

])neumonia,  272 
Joint-tuberculosis,  274 


K. 

Kansas,  69 

Kennedy,  Dr.  J.  F.  ,on  the  need  of  special 
institutions  for  the  consumptive  poor,  321 
Kentucky,  69 

Kissing,  Danger  in,  on  the  mouth,  46,  50 
Klebs,   Prof.  Edwin,  on  the  inoculability 

of  tuberculosis,  22 
Knopf's  aluminum  spittoon  for  use  at  the 
bedside,  41 
elevated  s|)ittoon,  38 
pocket  spuluni  (lask,  43 
table   showing  clinical   proofs  of 

pulmi    ary  tuberculosis,  329 
table  showing  pathological  proofs 
of  the  curability  of  pulmonary 
tuberculosis,  32 
Koch,    Robert,   on    the   infectiousness   of 

tuberculous  expectoration,  36 
Koch's,  Robert,  discovery  of  the  bacillus 

tuberculosis,  22 
Koumiss,  242 

"  Krankenheiin,"  Weicker's,  102 
K  rueger,  Dr.,  on  the  infectiousness  of  dust, 

36 
Kurbow's  experiments  with  latent   tuber- 
cles, 34 

L. 

Lactic  acid  in  laryngeal  tuberculosis,  269 
Laennec  on  the  curability  of  tuberculosis, 

on  the  unity  of  tuberculous  dis- 
eases, 22 


Laryngeal   tuberculosis    and    intercurrent 

diseases,  268 
Latent  tuberculosis,  34 
Latschenko  on  the  possible  tran<' mission  of 

tuberculosis  while  speaking,  55 
Laurentian  Sanatorium,  185 
Laws,  Sanitary,  in  the  United  States,  66 
I.ee,  Dr.  lienjamin,  on  the  need  of  special 
institutions  for  the  consumptive  poor,  321 
Lesions,  Seat  of  primary,  84 
Letterfrom  a  physician  in  the  Highlands,  20 
from  Dr.  Hallestre,  Nice,  37 
from  Dr.  V.  II.  .Atkins,  37 
from  Dr.  J.  .\.  Ilurty,  77 
Letulle,  Dr.,  on  the  need  of  special  hospi- 
tal for  consumptives,  320 
on  the  pathological  proofs  of 
the  curability  of  pulmonary 
tuberculosis,  32 
l.eyden.    Prof.    K.     von,     on     gavage    in 
pneumothorax,  272 
on  the  duration  of  cures  in  home 

climates,  203 
on  the  feasibility  of  the  treatment 
of  consumptives  in  all  climates, 
205 
on  the  need  of  special  institutions 
for  the  consumptive  poor,  320 
I.eysin,  Sanatorium  of,  124 
Liebe,  Dr.  (ieorg,  on  the  need  of  special 
institutions  for  the  consumptive  poor,  320 
Life,  Average,  of  the  tuberculous  laborer, 

308 
Ligation  of  limbs,  256 
Lindemann  on  ritual  circumcision,  53 
Lindsey,  Dr ,  on  the  need  of  special  insti- 
tutions for  the  consumptive  poor,  320 
List  of  sanatoria,  special  hospitals,  homes, 

etc.,  188 
Ixjcation  for  an  ideal  sanatorium,  205 

for  a  special  hospital,  294 
I-ongrois  on  the  history  of  contagion,  20 
Loomis,  Prof  II.    P.,  on  the  palhological 
proofs  of  the  curability  of  pul- 
monary tuberculosis,  32 
Sanitarium,  149 
Louisiana,  69 
Lupus,  Tuberculin  in,  2S7 
Lusk,  Prof   \V.    T.,  on  intervention  after 
tuberculous  conception,  318 

M. 

Maas,  Prof.,  on  ritual  circumcision,  53 

Maine,  69 

Millet,  Dr. ,  on   the  freeing  and  thawing 

of  tuberculous  subsU  ncc; ,  40 
Malnutrition,  244 

Management  nf  an  i<leal  sanaloriuiu,  21 1 
Mannheimer,   Dr.    Geo.,  on  the    need  of 

special  institutions  for  the   consumptive 

poor,  321 


iitercurrent 


'mission  of 
55 

■Jtates,  66 
:1  of  special 
'e  poor,  321 

ghlamls,  20 

37 
M 

:cial  liospi- 
ives,  320 
al  proofs  of 
pulmonary 

gavage    in 

res  in  home 

e  treatment 
all  climates, 

.  institutions 
;  poor,  320 

:1  of  special 
fe  poor,  320 
JUS  laborer, 


ion,  S3 
pccial  insti- 
poor,  320 
tals,  homes, 

m,  205 
294 
tagion,  20 
>aliioK>gical 
ility  of  pul- 
.32 


;ntion  after 


sion,  53 
id  thawing 


iriuni,  211 
le    need  of 
onsumptive 


INDEX. 


339 


Mnrcini,  Dr.,  on  the  pathological  proofs  of 
the  curability  of  pulmonary  tul)erculosis, 
32 
Maritime  Hospital  of  Berck-surMer,  118 
Marriage  relations,  281 
Martin,  Dr.,  on  the  ))athological  proofs  of 
the  curability  of  pulmonary 
tuberculosis,  32 
on  the  virulence  of  tubercu- 
lous udders,  67 
Maryland,  70 
Massachusetts,  70 

State  Hospital  for  Consump- 
tives, 167 
Massage,  264 
Maternity  sanatoria,  318 
May  on  the  dietetic  treatment  in  phthisis,  22 
Meat,  Destruction  of  tulierculous,  76 

'rul)erculous,  48 
Meat-powder,  Debove's,  250 
Meckel  on  the  pathological  proofs  of  the 
curability  of  ))ulnionary  tuberculosis,  31 
Medicinal,  Bacterio-,  treatment  of  fever,  262 
Cieneral,treatment  of  fever,  261 
Mendelsohn,    Dr.,    on  the  danger  of   bi- 
cycling in  pulmonary  tuberculosis,  291 
Menton,  Sanitary  condition  in,  37 
Metal  flasks.  Advantages  of,  43 
Meyer,  Dr.  Willy,  on  tuberculous  infection 

following  ritual  circumcision,  53 
Michigan,  70 

Mid  wives.  Tuberculous,  49 
Miliary  tuberculosis,  274 
Milk  as  diet,  238,  249 

problem.  Tuberculous,    solved  with- 
out the  aid  of  the  law,  77 
Tuberculous,  48,  67 
Miller,   )enness-,   system  of  dress  reform, 

23s 
Minnesota,  70 
Mississippi,  70 
Missouri,  70 
Moist  rags  for  patients  too    weak   to   use 

spittoons,  41 
Montan.),  70 
Montano,  Dr.,  on  the  theory  of  contagion, 

19 
Montc.lore  Country  .Sanitarium,  155 
Monthly  period,  282 
Morgagni,  Dr.  ,on  the  theory  of  contagion. 

Mortality  from  pulmonary  tulierculosis. 
Dial  showing  the  relative,  30 

from  pulmonary  tuberculosis, 
Hippocrates  on  the,  27 

from  pulmonary  tuberculosis  in 
Kngland  and  Wales,  307 

from  pulmonary  tuberculosis  in 
tlie  United  States,  28 

from  pulmonary  tuberculosis  in 
the  villages  of  (ioerbersdorf 
and  Falkenstein,  31 1 


Mortality   from    pulmonary     tuberculosis. 
Statistics  on  the,  27 
Table  showing  comparative,  in 
the  various  pursuits  of  life,  64 
Moschkowilz's,   Dr.,   case  of  tuberculous 
infection  through  ritual  circumci.sion,  53 
Mouth  breathing,  81 
Mouth-mask,  Prof.  Fraenkel's,  44 
Municipal  prophylaxis,  316 
Murrell,  Dr.,  on  the  infectiousness  01'  tu- 
berculous sputum,  36 
Muskoka  Cottage  .Sanatorium,  182 


N. 

Nahm's,  Dr.,  statistics  on  the  mortality  of 
tuberculosis  in  the  village  of  Falken- 
stein, 311 

Naples,  Royal  decree  of,  20 

Naunym,  I'rof. ,  on  the  durability  of  cures 
in  home  climates,  203 

Nebraska,  70 

Necro-tuberculosis,  47 

.Vervousness,  Kxtreme,  264 

Nervous  system,  Education  of  the,  to  the 
application  of  cold  water,  87,  226 

Neuralgia,  Intercostal,  253 

Nevada,  73 

New  Hamp.shire,  70 

New  Jersey,  70 

New  Mexico,  70 

New  York,  70 

Nice,  Sanitary  condition  of,  37 

Nicholas,  Dr.,  on  the  cural)ility  of  pul- 
monary tubercidosis,  34 

Nightingale,  Florence,  on  outdoor  life,  25 

Noorden,  I'rof.  von,  on  the  treatment  of 
phthisis  complicated  by  diabetes,  273 

Nordrach  colony,  1 13 

North  Carolina,  71 

North  Dakota,  71 

Nose-mask,  Dr.  Knopfs,  in  the  cabinet 
treatment,  222 

Nurses,  Training  of,  285 


O'jesity  in  tuberculous  patients,  270 
Oderberg,  Sanatorium  of,  1 14 
Ofl'spring,  Tuberculous,  283 
Ohio,  71 
Oklahoma,  71 
Oregon,  71 

()rnieroth,   I'rof,  on  pathological  proofs  of 
the  curability  of  pulmonary  tuberculosis, 

32 
Osier,  I'rof.,  on  pathological  proofs  of  the 

curability  of  pulmonary  tuberculosis,  32 
Otis,   Dr.    E.   O.,   on  the  need  of  special 

sanatoria  for  consumptives,  321 


. 


340 


INDEX. 


Kli" 


P. 

Packs,  Wef,  232 

Tains,    Pleuritic,  during   respiratory  exer- 
cises, 215 
Pasteur  Sanatorium,  157 
Pasteur's  maxim,  332 

Pathological  proofs  of  the  curability  of  pul- 
monary tuberculosis,  31-34 
Patients,  Cured,  283 

for  whom  health  resorts  are  suited, 
291 
Pavilion  for  isolation,  208 

system.  Large,  for  an  ideal  sana- 
torium, 207 
Pearson's,    Prof. ,  direction  for  inspecting 

herds,  74 
Pennsylvania,  71 

Society  for  the    Prevention 
of  Tuberculosis,  59 
Personal  hygiene  and  dress,  234 
Petit,  Dr.  I..  II.,  on  the  infectiousness  of 
the  saliva  of  consump- 
tives, 46 
on  the  need  of  special  in- 
stitutions for  consump- 
tives, 320 
Pliilanthropists,  WorV  for,  326 
Phthisio-genesic  diseases,  88 
Phthisic-therapeutists,  Education  of,  284 
Physical  means  to  comlvat  fever,  259 
"  Picquiire  analomique,"  51 
Pine  forests.  Artificial,  294,  306 
Pityriasis  versicolor,  273 
Pleurisy,  271 
Pleuritic  pains,  215 
Pliny  the  Elder  on  the  airof  pine-forests  in 

phthisis,  18 
Pneumatic  cabinet.  Action  of  the,  219 

IJescription  of  the,  218 

treatment,  Dr.  Knopfs 

modification  of   the, 

222 

treatment  in  laryngeal 

tuberculosis,  269 
treatment     in    emphy- 
sema, 265 
Pneumonia,  272 
Pneumothorax   272 

Pneumotomy  in  inilmonary  gangrene,  273 
Pocket  sputum  flask.  Dr.  Knopfs,  43 
I'ortal  on  the  history  of  contagion  in  tuber- 
culosis, 21 
JVecaution  during  the  rest  cure  in  the  open 

air,  215 
I'recautions  against  taking  cold,  277 

with  patient's  wardrobe,  295 
Preventive  treatment,  79 
Proedohl's  spittoon,  41 
Prognosis,  280 

I'ropagation  of  tuberculosis  through  spu- 
tum, 36 
Prophylactic  trer.tment  of  fever,  259 


Prophylaxis,  Individual,  35 

Public,  in  regard  to  tubercu- 
losis in  man,  56 
I'roverb,  Persian,  88 

Prudden,  Prof. ,  on  the  action  of  dead  bac- 
teria, 47 
on  the  need  of  special  in- 
stitutions  for  the  con- 
sumptive poor,  321 
Pueckler's  Sanatorium,  102 
Pulmonary  gangrene,  272 

tulierculosis.  Pathological 
proofs  of  the  curability  of,  31 


Q. 

Quimby  on  the  eflects  of  the  pneumatic- 
cabinet  treatment,  221 


Railway  cars.  The  need  of  regular  disin- 
fection o(,  60 
kanson  on  the  use  of  iodoform  in  phthisis, 

245 
Ravenel,  Dr.  M.   P.,  on  the   geographical 

distribution  of  bovine  tuberculosis,  67 
Raw  beef.  Preparation  of,  239 
Reclus,  Dr. ,  on   infection  through  sexual 

relation,  52 
Regimen,  Average,  238 
Reilioldsgriln,  .Sanatorium  of,  109 
Reid,  Thomas,  on  blood-letting  in  phthisis, 
21 
on    the   ventilation   of   the 
House  of  Lords,  88 
Reinfection  of  upper  air-passages,  42 
Renvers,    Prof. ,  on   pathological  proofs  of 
the  curability  of  pulmonary  tuberculosis, 
32 
Reporting,    Compulsory,    of    tuberculous 

cases,  56 
Respiration,  Artificial  mouth-to-mouth,  49 
Respiratory  exercises,  82 
Rest  cure,  213 

arrangement  at  home,  303 
in  fever,  259 
Restriction,  Legislative,  of  immigration  of 

tuberculous  patients,  292 
Resulls,  Average,  obtained  by  culture  prod- 
ucts and  other  specific  remedies, 
288 
obtained  by  municipal  prophylaxis. 
216 
in   general  hospitals,  313 
in  home  climates,  203 
in    hospitals  for  tuliercu- 
lous     and     .scrofulous 
children,  314 


III?-— li 
■J  t 


i 


INDEX. 


341 


Results  obtained  in  sanatoria  for  consump- 
tive poor,  314,  329 
^  in   sanatoria    for    paying 

patients,  239 
Respiratory  exercises  in  ciironic  hemopty- 
sis, 257 
in  emphysema,  265 
in  laryngeal  tubercu- 
losis, 269 
in  the  curative  treat- 
ment, 215 
in      the     |)reventive 
treatment,  82 
"  Revue  de  la  Tuberculose,"  25 
Revulsion  in  the  treatment  of  pulmonary 

tuberculosis,  253 
Rhode  Island,  71 
Riviere,  I.azare,  on  the  contagious  nature 

of  tuberculosis,  19 
Koempler's  sanatorium,  loo 
Rogee,  Dr.,  on  the  curability  of  pulmonary 

tuberculosis,  32 
Rokitanski  on  the  curability  of  pulmonary 

tuberculosis,  31 
Room,  Hygiene  of,  47,  302 
Rose,  Dr.,  on  the  need  of  special  institu- 
tions for  the  consumptive  poor,  321 
Royal  Hospital  for  Diseases  of  the  Chest 
at  Ventnor,  130 
Sea-bathing   Infirmary  for  Scrofula, 

23 
Ruck,  Ur.  Karl  von,  on  the  duration  of 
cure    obtained   in 
sanatoria,  330 
on    the    etiology   of 
tuberculosis,  67 
Ruppert.shain,  Sanatorium  of.  94 
Rush  Hospital  for  Consumption,  164 


S. 

Sanatoria  as  educators,  310 

for  consun'.piives  no  danger   to 

the  neip'  borhood,  311 
for  school  children,  319 
for  the  consumptive  poor,  307 
forthe  consump'ive  poor,  Results 

obtained  in,  314 
Visits  to,  90 
Sanatorium,  Definition  of,  200 
Sanitary  conditions  in  Menton,  37 

New  Mexico,  37 
Nice,  37 
laws  in  the  United  States,  06 
Saugm.mn,  Dr.  Chr.,  on  the  need  of  sana- 
toria for  the  consumptive  poor,  320 
Schmidt,  Prof.,  or.  laryngeal  tuberculosis, 

268 
Schonlein  on  climatic  treatment,  22 
School  children,  Sanix'orin  for,  319 


School  of  "  Prophylaktiker,"  Dr.  Turban's, 

physician's  duties,  60 
Scliools,  'i'uberculous  children    in   ])ublic, 

60,319 
Schrotter,  Prof,  von,  on  the  need  of  special 
institutions  for  the 
consumptive    poor, 
320 
on  street  sweeping,  62 
•Schuchardt,  Dr.  K.,  on  tuberculous  infec- 
tion through  sexual  relations,  52 
Serums,  238 
Seton  Hospital,  159 
.Sexual  relations,  Infection  through,  52 
Sharon  Sanitarium,  165 
Shrady,   Dr.  G.    I".,  on  the   Ir.atment  of 

tuberculous  patients  in  sanatoria,  332 
Singing  and  aerotherapeutics,  86 
Site  for  an  ideal  sanatorium,  204 
Smith,  Dr.  F.  \V.,  on  bovine  tuberculosis, 

67 
Society,  Pennsylvania,  for  the   Prevention 

of  Tuberculosis,  59 
Soil  for  an  ideal  sanatorium,  204 
Solly,  Dr.,  on  the  use  of  atropine  in  hem- 
optysis, 255 
.Soups,  Mucilaginous,  240 
South  Carolina,  71 
South  Dakota,  7 1 

Special  hospitals.  Treatment  of  toiisuniii- 
tives  in,  294 
in.stit'.itijns    for    the    consumptive 
poor,  307 
.Spilhnann,   Dr.,   on  the  dissemination   of 

bacilli  through  (lies,  40 
Spittiiig-cui),  Seabury  and  Johnson's,  41 
Spittoon,  Dr.  Knopf's  elevated,  38 

for  factory  and  workshop,  of  Dr.  ' 
Proedohi,  41 
.Sports,  290 
Sputum,  Expulsion  of,  43,  55 

flask,  Dr.  Knopf's  pocket,  43 
Standacher,  Dr.,  on  pathological  proofs  of 
the  curability  of  pulmonary  tuberculosis, 
32 
Starke,  Dr.  G.  H.  E.,  on  atropine  in  hem- 
optysis, 255 
State  insurance  aj^ainsl  tuberculosis,  324 
.Slutistic.-.,  Knopf's,  on  clinical  proofs  of  the 
curability  of  pulmo- 
nary tuberculosis,  329 
on   pathological   proofs 
of    the    curaliilily  of 
pulmonary     tubercu- 
losis, 32 
on  the  mortality  from  pulmonary 

tuberculosis,  27 
showing  decrease  in   the  death- 
rate  in  villages  with  sanatoria, 

3" 
St.  Joseph  Hospital,  New  York,  160,  317 


342 


INDEX. 


Slrassninnn,  Prof.,  on  tlip  curability  of  jml- 

nioiinry  tiii)C'rculosis,  j^ 
Straus,  I'rof.  I.,  on  tlie  inoculabilily  of  piil- 
iiKiimry  liilierculosis,  _}6 
oil  tilt;  trnnsiiiission  of  tli 
lierciilosis    tiiroii^li    tlu' 
parrot,  50 
Street  sweeping,  I'rof.  von  Scli rotter  on,  62 
Sluliljert,  Dr.   J.   E.,  on    nntistreptocociic 
serum,  20J 
on  the  use  of  iclilliyol 
in   pulnioimry  tu- 
herculosis,  246 
Submersion,  Thalassic,  65 
Suggestive   treatment   of  pulmonary  hem- 
orrhage, 255 
Sun-ballis  for  cliildren,  82 
Supervision  of  faetories,  worksliops,  stores, 
etc.,  63 
of  pulilic  instituti'.ns,  57 
Surgical  measures   in  laryngeal  tuberculo- 
sis, 269 
Susceptibility  to  catarrhs,  80 
Sweat-baths  in  hyperhidrosis,  254 
Sydenham  on  horseback-riding  in  phthisis, 

19 

Sylvius,  jacobus,  on  scrofula  and  tubercu- 
losis, 18 
Symptomatic  treatment  of  laryngeal  tuber- 
culosis, 268 
of    pulmonary   tu- 
berculosis, 244 
Syphilis  predisposing  to  tuberculosis,  65 


Table   showing   comparative  mortality  in 

various  pursuits  of  life,  65 
Tappeiner,    Dr.,  on    the   inoculability   of 

tuberculosis,  36 
'I'arnier,  I'rof,  on  intervention  in  tul>ercu- 

lous  conception,  318 
Tatham's  statistics  on  the  mortality  from 

pulmonary  tuberculosis  in   Kngland  and 

Wales,  307 
Tattooing,  Tuberculous  infection  through, 

54 
Teeth,  Care  of  the,  241 
Temperature   an   indication    for    exercise, 
217 
Taking  of,  258 
Tenement  houses,  The  need  of  model,  65 

Visit  to,  308 
Tennessee,  72 
Texas,  72 

Thalassic  submersion,  63 
Time  needed  to  accomplish  a  cure,  2S4 

temperature,  and  duration  of  douche, 
322 
Tonsaasen,  Sanatorium  of,  126 


Torek,  Dr.  Franz,  on    Hier's  treatment  in 

joint  tuberculosis,  274 
Training  of  nurses,  285 

school  for  nurses,  155 
Transformation,   Calcareous,  of  tul)ercles, 

.34 
Fibrinous,   of    tubercles, 

Traube  on  respiratory  exercises  in  chronic 

hemoptysis,  357 
'i'rcatmciit.  Dietetic,  of  pulmonary  tubercu- 
losis, 237 
educational,  of  tuberculous  pa- 
tients, 277 
in  sanatoria,  2cx) 
of    ambulant    tuberculous    pa- 
tients, 297 
of  consumptives  at  their  homes, 

302 

of  consumptives  in  special  hos- 
pitals, 294 
of  patients   in   the  dispensary, 

297 
of  (latients  sullering  from  laryn- 
geal tuberculosis,  268 
of  pulmonary  tuberculosis,  Cli 

mato-thtrapy  in  the,  200 
of  tubiMTulosis  ot   llio  child  in 

utero,  81 
I'reventive,  79 
Tricycle,  291 
'i'ro|K)n  as  food,  24 1 

Trudcau.  Dr.  V..  I,.,  on  sanatoria,  25,  321 
Tuberculin,  286 
"  Tuberculose  Infantile,"  26 
Tuberculosis,  liovine,  66 

committees  and  their  duties, 

322 
"  F.ndemic,"  32^ 
experimentally  [iroduced,  36 
in  domestic  pet  animals,  50 
in  swine,  horses,  goats,  etc., 

78 
Intestinal,  49 
Miliary,  274 

of  the  joints  an<l  bones,  274 
of  the  testicle.  Dr.   Torek's 

case  of,  27s 
Tuberculous  children  in  jjublic  schools,  60, 

.319 
meat,  Destruction  of,  76 
milk  problem  solved  without 

the  ai<l  of  the  law,  77 


U. 

Udders,  Virulence  of  tuberculous,  67 
Ulsperger   on    the    pathological    proofs  of 
the  curability  of  pu  monary  tuberculosis, 

31 
Under-garmcnts,  234 


iitiiipnt  III 


f 


INDEX. 


343 


UDited  States  Marine  Hospital  Service  for 
'rulicrciiloiis  I'alicnis,  199 
'       Sanitary  laws  in  tlie,  66 
Unsanitary  lialiilatioiis,  63,  326 
Usciloin's  Ijiculliiiig-ciiuir,  216 
Utali,  72 

V. 

Vaccination,  Tulicriuloiis infection  tlirou^li, 

52 

VahiL-  of  isolation,  317 

Van    Ileliiiont   on   the   usu  of  aicoiiol    in 

plitliisis,  19 
Van  Swieten  on   the  contagious  nature  of 

phtliisis,  19 
Ventnor,    Koyal    Hospital  for  Diseases  of 

liic  (!hest  at,  130 
Vest  suspender,  235 
Vermont,  72 
Vill)frt,  lir.,on  llie  path(iU)(^ital  proofs  of 

the  curahiiitv  of  pulmonary  lulierculosis, 

Victoria  Hospital  for  Consumptives,  136 
Villemin  on  the  inoculahility  of  tubercu- 
losis, 22 
Virchow,  I'rof.,  on  pathological    proofs  of 
the  curaliility  of  pulmonary  tuberculosis, 

3« 
Virginia,  72 

Virulence  of  the  bacilli  exjiosed  to  cold,  40 
retained  after 
burial,  51 
of  tuberculous  udders,  67 
Visit  to  a  tenement  home,  308 
Visits  to  sanatoria,  90 
Vomiting,  253 


w. 

Walker,  I)r.,  on  the  pathological  proofs  of 
the  curability  of  pulmonary  tuberculosis, 

32 

Walking  exercises,  217 

Walters,   Dr.    Kufiiacht,   on    sanatoria  for 

consumplives,  320 
Walther's,  I  )r.  Otio,  sanatorium,  1 13 
Wardrobe,  IVecaution  with  jiatieiit's,  295 
Ware,  Dr.,  on  tuberculosis   following  cir- 
cumcision, 53 
Washington,  State  of,  73 
Weakness,  Kxireme  state  of,  264 
Weather  in  consumptives,  Ulumenfeld  on 
the  influence  of,  205 


in  antistreptococcic 


Weaver,  iJr.  W. 

serum,  263 
Weber,    Dr.    !•'.    I'.,   on    the    pathological 
jiroofs  of  the  curability  of  pul- 
monary tuberculosis,  32 
Weber,  Dr.  Ilermanii,  on  the  feasibility  of 
treating  consump- 
tives     in      moist 
climates,  205 
on  the  infection 
ihrough     inocula 
lion,  52 
on    the    need   of 
special  institutions 
for  the  coiisump 
tive  poor,  320 
Weber's  case  of  twice-healed  tuberculosis, 

3.5. 
classification  of  climate,  201 
Weicker's  "  Krankeiiheim,"  102 
Weir  Mitchell's,  Dr.,  treatment  in  extreme 

weakness,  264 
Welsh,   I'rof.,  on  the  inoculahility  of  pul- 
monary tuberculosis,  22 
Werdmiiller,     Dr.,     on    the    pathological 
proof  of    the    curability   of    pulmonary 
tuberculosis,  31 
West  Virginia,  72 

Wet-nurse,  Infection  from,  to  child,  52 
Whittakcr,  I'rof,  on  the  pathological  evi- 
dences of  pi'  'visling  tuberculosis,  34 
Willis,  of  I-oiiiiun,  on  the  climatological 

treatment  in  phthisis,  19 
Winternitz  on  hydrotherapy  in  hemoptysis, 

256 
Winyah  Sanitarium,  173 
Wisconsin,  72 

Wise,  Dr.  T. ,  on   consumption  and  cana- 
ries, 50 
on    the   life    of    (leorge 
liodington,  23 
Woltf-Immermann,  J)r.,on  the  educational 

treatment  in  hemoptysis,  255 
Wood-vinegar  as  disinfectant  for  tubercu-  > 

lous  .secretions,  45 
Work  lor  philanthropists,  326 

for  a  central  bureau  to  combat  bo- 
vine tuberculosis,  74 
Wyoming,  72 


Ziemssen,  Dr.  von,  on  the  duration  of  cures 
in  home  climates,  203 


H 


l  ' 


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-List  of  about  300  Standard  Books  classified  by  Subjects. 

, — Morris'  Anatomy ;  Gould  and  Pyle's  Cyclopedia ;  Deaver's  Surgical 
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ANATOMY. 
Ballou.     Veterinary  Anat.     fo.So 
Broomell.       Anatomy    and 

Histol.  of  Mouth  and  Teeth.  4.50 
Oordinier.  Anatomy  of  Nerv- 
ous System.     Illustrated.        600 
Heath.    Practical.    7th  Ed.     4.35 
Holden.  Dissector.    2  Vols.     3  00 

Osteology.     8th  Ed.      5.25 

Landmarks.     4th  Ed.     .75 

Macalister's   Text-Hook.     -    5.00 
MarshuU's    Phys.  &  Anatom- 
ical Diagrams,     j^o.oo  anci  60,00 

Morris.  Text-Book  Anat.  New 
Ed.  790  111.     Clo  ,f6.oo;  Sh.,  7.00 

Potter.  Compend  of.  6th 
Ed.     133  Illustrations.  -  .80 

Wilson's  Anatomy,  nth  Ed.  5.00 

Windle.    Surface  Anatomy,    i.oo 

ANESTHETICS. 
Buxton.     Anesthetics.     -  1.50 

Matas.       Local     Anesthesia 

with  Cocain,  Eucain,  etc. 

Turnbult.    4ih  Ed.  -         2.50 

BACTERIOLOGY. 
Conn.      Agriculturid    Bacteri- 
ology.    llUistralcd.       -      -    ■'^— 
Hewlett.    Manual  of     lUus.     j.oo 
Williams.     Student's  Manual 
of.     2d  Edition.     90  IDus.       1.50 

BRAIN  AND  INSANITY. 
Blackburn.     Autopsies.     -       1.25 
Horsley.  Brain  and  Sii,  Cord.   2.50 
Ireland.     Mental    Aflcctions 

of  Chddren  -  -  -  4.00 
Lewis.  Mental  Diseases.  7  00 
Mann's  Psychological  Med.  3.00 
Rigis.  Mental  Medicine.  -  2.00 
Shuttleworth.  Mentally  De- 
ficient Children.  -  -  1.50 
Stearns.  Mental  Dis  lllus.  2.75 
Tuke.  Dictionary  of  Psycho- 
logical Medicine.  2  Vols.  10.00 
Wood.    Brain  and  Overwork.     .40 

CHi':MISTRY. 
Ttchnol'g'l  Hooks,  Wattr,Milk, 
Allen.     Commercial    Organic 


Analysis.     Vol.  1, 

Vol.  II.     Parti. 

Vol    11.     P.irtll.      - 

Vol.  11.     Part  III.    - 

Vol.111.     Parti.     . 

Vol   HI.     Part  11.    - 

Vol.  HI.     Part  111.- 

Vol.  IV.      -         -       - 

Bartley.     Medical  and  Phar- 
maceutical.    5th  Ed. 

Clinical  Chemistry. 

Btoxain's  Text-Book.  8th  Ed. 
Caldwell.      Qualitative    and 

Quaiuitative  Analysis. 
Cameron.     Oils  &  Varnishes. 

Soap  and  Candles.     - 

Clowes  an  '  Coleman.  Quan- 
titative Analysis.     5th  Kd.  - 

Coblentz.     Volumetric  Anal. 
Congdon.     l.ahoratory.  - 
Gardner.     Brewing,  etc. 
Qroves  and  Thorp.     Chemi- 
cal Technology,  vol.  I.  Fuels 
.  Vol.  II.     Lighting. 


,etc, 

4.50 
350 

3-5° 

4.50 
4.50 
4.50 

4.50 

3.00 
1.00 

4.'5 

I.  CO 

2.25 


I  00 
1.50 

5.00 
4.00 
3  50 


Vol.  111.  Cas  Lighting. 

Vol.  IV.  Elec.  Lighting. 

Holland.  Urine,  Gastric  Con- 
tents, Poisons  and  Milk  Anal- 
ysis, 6th  K<1.        -        -        -     1,00 

Leffmann's  Compend,         •      .80 

EoocI  Analysis.      -      -     

Milk  Analysis.     -       -     1,35 

— — —  Water  Analysis,  -         -     1.25 
^■^^  Structural  Formulse,  -     i,oc 


Muter.     Pract.  and  Anal, 
Oettel.     Electro-Chem. 

—  Electro-Chcm.  Exper. 

Richter'B  Inorganic.    5th  Ed, 

Organic,  jd  Ed,  2  Vols 

Vol.  I.  Aliphatic  Series, 
Vol.ll.Carbocyclic 


»I,25 

■75 

•75 

••75 

3,00 
3.00 
1.25 


Smith.  Electro-Chem.  An.'d, 
Smith  and  Keller.  Experi- 
ments. 4th  Ed.  lllus,  .60 
Sutton.  Volumetric  Anal.  5,00 
Symonds.  Manual  of.  2.00 
Traube.  Physico-Chem.Meth.  1.50 
Thresh.  Water  Supplies.  -  a. 00 
Ulzer  and  Fraenkel.  Tech- 
nical Chenucal  Analysis.  1.35 
Woody.  Essentials  of.  4th  Ed,  1.50 

CHILDREN. 
Hale.     Care  of  -  .50 

Hatfield.     Compend  of.  .3o 

Meigs.     Milk  Analysis.  -  .50 

Power.   Surgical  Diseases  of.  2.50 
Smith.    Wasting  Diseases  of    200 

Starr.    Digestive  Organs  of.      

Hygiene  of  the  Nursery. i.oo 

Taylor  and  Wells.  Manual.  4,50 

CLINICAL  CHARTS. 
Griffith's      lenip't're  Charts, 

Pads  of  50  -        .  -  .50 

Keen.     Outline    Drawings    of 

Human  Body.        -        -  i.oo 

Schreiner.   Diet  Lists.    Pads,  .75 

COMPENDS 
And  The  Quii-Comftndi. 

Ballou.     Veterinary  Anat.  ,80 

Brubaker's  Physiol,  loth  Ed.  .80 

Cushing.     Histology       -    -  .80 

Gould  and  Pyle.     The  Eye,  .80 

Hatfield.     Children.  -  .80 

Horwitz.     Surgery,     5th  Ed.  .80 

Hughes.   Practice.  2  Pts.  Ea.  .80 

Landis.    Olistetiics.    6th  Ed,  .80 

Leffmann's  Chemistry.  4lh  Ed.  .80 

Mason.     Electricity,        -  .75 

Potter's    Anatomy.  6th  Ed.  .80 

:-. Materia  Medica.  6ih  Ed,  .80 

Schamberg.     Skin  Diseases,  ,80 

Stewart,  Pharmacy,  5th  Ed,  .80 

Thayer,     Pathology.       -     -  ,80 

Warren.     Dentistry.    3d  Ed  .80 

Wells,     Gynecology,    2d  Ed.  .80 

Self  -  Examination.         3500 

Questions  on   Medical    Suh- 

jects.  -  -  Paper,  .10 

Any  of  above,  Interteaveil,  $1.00. 

CONSUMPTION. 
Harris  and   Beale.      Pulmo- 
nary Consumption,      -         -     3.50 
Knopf.  Pulmon. Tuberculosis,  3,00 
Steel.     Physical  Signs  of  Pul- 
monary Disease.      -      -     -    1,35 

DENTISTRY. 
Barrett.     Dental  Surg. 


Broomell.    Anat.  and  Hist,  of 

Mouth  and  Teeth,     - 
Fillebrown.   Op.  Dent,  lllus. 
Qorgss.     Dental  Medicine. 
Harris.     Principles  and  Prac. 

Dictionary  of.     6th  Ed. 

Heath.     Dis.  of  Jaws. 
Richardson.    Mech,  Dent, 
Smith.     Dental  Metallurgy, 
Taft.     Index  of  Dental  Lit. 
Tomes.     Dental  Surgery, 


Dental  Anatom 


my, 
of. 


I.oo 

4.50 
a. 35 
4.00 
6.00 
5.00 
4'5o 
5.00 

••75 

3.00 

4.00 

4,00 

,80 


Warren's  Compend 

Dental    Prosthesis  and 

Met.tllitrcy.      lllus,        -  1,35 

White.    Mouth  and  Teeth.        .40 


DIAGNOSIS 
Brown.    Medical.    4th  Ed.  ^1,25 
Fenwick     .Medical.   8th  Ed,    3.50 
Tyson's  Manual,  3d  Ed.  lllus,  1.50 

DICTIONARIES, 
Gould's  Illustrated  Dictionary 
of  Medicine,  Biology,  and  Al- 
lied Sciences,  etc,     5th  Edi- 
tion,    Leather,  Cio.oo;  Half 
Russia,  Thumb  Index,    -      13.00 
Gould'sStudent's  Medical  Die-  j 
tionary,      nth    Ed.,  lllus,,  Ji 
Mor.,  52.50:    Thumb  Ind..    3,00 
Gould's    Pocket  Dictionary —  ^ 
30,000  medical  words.     4th       ? 
Edition.  Enlarged.  Leather,  1.00 
Gould  and  Pyle.   Cyclopedia 
of  Med.  and  Surg.     One  Vol. 
lllus.  Leather,  10.00 

Harris'  Dental.  Clo.  5.00;  Shp.  6.ro 
Longley's  Pronouncing.  .75 

Maxwell.  TerininologiaMed- 

ica  Polyglotta.  -        -        3.00 

Treves.    German-English.       3.25 

EAR. 
Burnett.     Hearing,  etc.  .40 

Dalby.    Diseases  of.   4th  Ed.  3.50 
Hovell.     Treatise  on,  -     5,50 

Pritchard.  Diseasesof.  3dP2d.  1.50 

ELECTRICITY. 
Bigelow.  Plain  Talks  on  Medi- 
cal Electricity.     43  lllus.  1.00 
Hedley.     Therapeutic  Elec,     3,50 

Jacobi.     Electrotherapy 

Jones.       Medical    Electricity, 
3d  Ed.     lllus.  -  3.00 

EVE, 
Dondera.  Refraction.  -  1,25 
Fick.  Diseases  of  the  Eye.  4,50 
Gould  and  Pyle  Compend,  .80 
Gower's  Ophthalmoscopy.  4.00 
Harlan.     Eyesight.  -  .40 

Hartridge.  Refraction,  loth  Ed.  1.50 

Ophthalmoscope.  3d  Ed,  1.50 

Hansen   and    Reber.     Mus- 
cular Ail.unolies  of  the  Kye.  1.50 
Hansen  and   Bell.    Clinical 

Ophthalmology,  120  lllus,  1.50 
Jessop's  Manual  of  Diseases 

of  F,yc.  -  .  .  -  3.(10 
Morton.  Refraction,  6th  Ed,  1.00 
Ohlemanr.  Ocular  Therap.  1.75 
Phillips.   Spectacles  and  Eye- 

gl.'isscs.  40  lllus,  2d  Ed,  i,iH3 
Swanzy'i  Handhook.  7th  Ed.  2.50 
Thorington.     Retinoscopy.      100 

Kefraction.     200  lllus,  i.so 

Walker.     Student's  Aid.  1.50 

Wright.     Ophthalmology.       3, to 

GYNECOLOGY. 
Bishop.      Uterine   Kihromyo- 

mata.  Illustrated,  -  -  3.50 
Byford  (H.  T.).     Manual.   2d 

Edition,  341  Illustrations,  3,00 
Diihrssen.     Gynecologicr.l 

Practice.  105  Illustrations,  1.50 
Montgomery.        I'ext-book 

of,  527  lllus.  -  ,  .  5.00 
Lewers.  Dis,  of  Women.  2.511 
Wells.    Compend.     lllus.  .80 


HEALTH  AND  DOMESTIC 
MEDICINE. 
Bulkley.    The  Skin, 
Burnett.     Hearing. 
Cohen.     Throat  and  Voice, 
Dulles.  F.mergencies.  5th  Ed 
Harlan,     Eyesight. 
Hartshorne.    Our  Homes. 


•40 
.4c 
•4ti 
I.iv_' 
4" 
•  4C- 


ICES, 


iblished. 
Catalogue. 

r,NOSIS 
/.A.     4th  Ed.   ^3.35 

:iical.    8th  Ed.    2.50 
1.  3d  Ed.  lilus.  1.50 

ONARIES. 
ated  Dictionary 
Biology,  and  Al- 
,  etc.     5th  Edi- 
:r,  tio.cx);   Half 
nb  Index^    -       12.00 
t's  Medicnl  Uic-  | 
Ed.,  Illiis.,  ^ 
rhnmb  Ind..    3.00 
i   Dictionary —  ^ 
..  words.      4th        ^ 
rged.  Leather,  i.oo 
'le.   Cyclopedia 
Surg.     One  Vol. 

Leather,  10.00 
CIo.  5.00;  Shp.  6.ro 
nnouncing.  .75 

rminologia  Med- 
a.  •        -        3.0^ 

nan-English.        3.?5 


al 


EAR. 

aring,  etc.  .40 

Lses  of.  4th  Ed.  2.50 
itise  on.  -     5.50 

iseasesof.  jd  Kt\,  1.5a 

:tricity, 

in  Talks  on  Medi- 
y.     43  IIliis.  I.oo 

erapeiiiic  Etec  2.50 
Irotherapy  -  -— 
ical    Electricity, 


1.25 

4.?o 
.80 

4.00 
40 


EYE. 

efraction. 

;cs  of  the  Eye. 

y!e.  Conipend. 

ithalinoscopy. 

:.sighl. 

efraction .  i  oth  Ed .  i .  50 

hnoscope.  3d  Ed.  1.50 

1   Reber.     Mus- 

alies  of  the  Eye.  1.50 

Bell.    Clinical 
:)gy,      120  llhis.      1.50 
iiiial  of  Diseases 

3.00 

T.OO 


■75 


fraction,  6(h  Ed. 
Jcular  Therap, 
ictacles  atid  Eyc- 
Ilhis.  2d  Ed.  1..0 
mdhook.  ylh  Ed.  2,50 
Retinoscopy.  1 .00 
ction.  200  IlIiis.  1.50 
iident's  Aid.  1.50 

>hihalmology,        3.t'o 

ECOLOGY. 

erine    Fihromyo- 

ilrated,       -      -      3.50 

P.).     Manual.   2d 

fi  IlUistrations,     3.0a 

Gynecological 

03  Illustrations.    1.50 

y.       Text- book 

;«.      -         -        .     5.00 

s.  of  Women.        2.51) 

ipend.     Illus.  .80 

/VNO  DOMESTIC 
DICINE. 

leSkin.        -  .40 

earing.  -  .4'. 

oat  and  Voice.  .40 
rgcncies.  5th  Ed.  1.00 
esight.  -  .40 

Our  Homes.        .4c 


H 


m 


CLASSIFIED  LIST  OF  P.  BLAKISTON'S  SON  &*  CO.'S  PUBLICATIONS. 


Osgood,  Dangers  of  Winter,  fo. 40 
Packard.    Sea  Air,  etc.  ,40 

Richardson's  Long  Life.  .40 

White.  Mouth  and  Teeth.  .40 
Wilson.  Summer  and  its  Dis,  .40 
Wood.    Brain  and  Overwork.    .40 

HiSTOLOGY. 
Cushing.    Compend.     -     -      .80 
Stirling.    Histologjr.  id  Ed.   3.00 
Stohr's  Histology.  Illus.     -    3.00 

HYGIENE. 
Canfield,  Hygiene  of  the  Sick- 
Room.      -        -        -        -        1.25 

Coplin,     Pr.ictical  Hygiene.    

Ernst.  Prophylaxis.  -  -  — - 
Kenwood.       Public     Health 

Laboratory  Guide.  -  a.oo 
Lincoln.  School  Hygiene.  .40 
McNeill.  Epidemics  and  Iso- 
lation Hospitals.  -  -  3.50 
Notter.  Practical  Hygiene.  7.00 
Parkes'  (L.  C),  Manual.         3  00 

Eleme.its  of  Health.       1.25 

Starr.  H  y({iene  of  the  Nursery,  i.oo 
Stevenson  and  Murphy.  A 

Treatise  on  Hygiene.     In  3 

Vols.     Circular        Vol.  1,    6.00 

upon  attlicatioH.     Vol.11,    6.00 

Vol.111,   5.00 

Thresh.     Water  Supplies.        a.oo 

Wilson's  Handbook.  8th  Ed.  3.00 

Weyl.     Coal- Tar  Colors,  1.25 

.M.ASS.-^GF.,  Etc. 
Kleen  and  Hartwell,      -       1.23 
Mitchell  and  Oulick.     Me- 

chantulier:^py.    -        - 

Ostrom,  Massage.  105  Illus.  1.00 
Ward,    Notes  on.   Paper  Cov.  1.00 

MATERIA  MEDICA. 
Biddle.   13th  Ed.    Clo;h,         4.00 
Bracken.     Materia  Med.  3.75 

Coblentz.  Newer  Remedies,  i.oo 
Davis.     Essentials  of.  -     1.50 

Gorgas.  Dental.  5th  Etl.  4.C0 
Gron.  Mat.  Med  for  Nurses.  1.35 
Heller.     Essentials  of.  -    1.50 

Potter's  Compend  of.  6lh  Ed.  .80 
Potter's    Handbook    of.     8th 

Ell.  Cloth,  ifs. 00:  Sheep,  6.00 
Sayre.  (Organic  Materia  Med. 

and  Pharmacognosy.       -        4.50 
White  and  Wilcox.     Mat. 
Med,,  Pharmacy, Pharmacol- 
ogy, and  Therapeutics.    4th 
Ed.  Enlarged.  CI. ,13.00;  Sh.  3. 50 

MEDICAL  JURISPRUDENCE. 
Mann.     Forensic  Med.        -      6.50 
Reese.  Med.  Jurisprudence  and 
Toxicology, 5th  Kd  >3.oo;Sh.  3,50 
MICROSCOPE. 
Carpenter.    The  Microscope. 

8th  Ed.     800  Illus.  -       

Lee.  Vade  Mecum  of.  5th  Ed.  4.00 
Reeves.   Med.  Microscopy.      2.50 
Wethered.     Medical  Micros- 
copy.    Illus.       -        -        -     2. 00 
MISC  '.LLANEOUS. 
Black.     Mijro-organisms.  .75 

Burnet.     Food  and  Uietar'cs.  1.50 

Cohen.    Organotherapy.  

Da  Costa.    Clinical  Pathology 

of  the  lllood.        -        -         -    

Davis.     Alimenrotherapy.       

Duckworth.  O.itJout.  -  6.00 
Fenwick.  Ulcer  i.l  Momrich.  3.50 
Goodall    and    Washbourn, 

Inleclions  Diseases.  Illus.  3.00 
Gould.  Borileil.ind  Similes,  a.oo 
Greene.   Mc'iual  Examination 

in  l.iie  Insurance  Mus.  -  4.00 
Haig.     Uric  Acid.     5th  Ed.      3.00 

Diet  aiul  Kood.  3d.  Ed.  i.oo 

Hare,     Mediastinal  Disease,    a.uo 
Hemmeter,  Diseases  of  Stom- 
ach.   2d  Edition.    Illus.    -    600 

Diseases  of  Intestines. 

Henry,  Anaemia.  -  -  .50 
Leffmann.  Coal  Tar  Products.  1.25 
McCook,  Amer.  Spiders,  50.00 
New  Sydenham  Society's 

Publications,  each  year.     -    8.00 
Osier  and  McCrae.  Cancer 
of  the  Stomach     -        .        .  2.00 


St.  Clair.    Medical  Latin,      fi.oo 
Thome.    Schott  Methods  in 
Heart  Disease.        -        -  1.75 

Tissier.     Pneumatotherapy.    

Treves.     Physical  Education.    .75 
Weber  and  Hinsdale.    Cli- 
mate,  -----     

Winternitz.    Hydrotherapy. 

NERVOUS  DISEASES,  Etc. 

Beevor,     Nervous  Diseases.    3,50 

Dercum,  Rest,  Mental  Tliera- 
peiitics,  Suggestion,        -        

Gordinier,  Anatomy  of  Cen- 
tral Nervous  System.      -        6.00 

Qowers.  Manual  of,  530  Illus. 
Vol.  I, $4. 00;  Vol.3,         -        4,00 

Syphilis  and  the  Ner- 
vous System.      -        -        -      i.oo 

Clinical  Lectures,  2.00 

^-— ,  Epilepsy,    New  Ed.      

Horsley,      Hrain  and    Spinal 

Cord.  Illus,  -  -  -  2.50 
Ormerod,  Manual  of,  -  i.oo 
Osier.  Chorea.  -  -  3.00 
Preston,     Hysteria.     Illus.     2.00 

NU.<SING. 
Canfield.  Hygiene  of  the  Sick- 

Koom,  -  -  -  -  1.25 
Cuff,  Lectures  on,  ad  Ed,  1.35 
Domville's  Manual,    8th  Ed.   ,75 

Ernst.     Prophylaxis.  - 

FuUerton,     Obst.  Nursing,      1.00 

Surgical  Nursing,  1,00 

Gould,  Pocket  Medical  Dic- 
tionary      Limp  Morocco,        i.oo 

Groff,  Mat,  Med,  for  Nurses.  1.25 
Humphrey,  Manual.  17th  Ed.  i.oo 
Starr.  Hygiene  of  the  Nursery.  1,00 
"Temperature  Charts,  Pads,  .50 
Voswinkel,     Surg.  Nursing,    i.oo 

OBSTETRICS. 
Cazeauxand  Tarnier.   Text- 
Hook  of.     Colored  Plates,       4.50 

Edgar,      Text  Book  of.        -    

Landis,  Compend.  6th  Ed,  ,80 
Winckel's  Text-book.  5.00 

PATHOLOGY. 
Barlo^v.    General  Pathology.  5.00 
1.25 
3- 50 

.80 

•75 

1.50 

3. 00 
2.00 

3-50 

3.00 
••75 


PRESCRIPTION  BOOKS. 
Beasley's  3000  Prescriptions.  JI2, 00 

Receipt  Book.        -         2.00 

Davis.     Materia  Medica  and 

Prescription  WriiMig.     .         1.50 

SKIN, 
Bulkley.    The  Skin.        -  .40 

Crocker,    Dis,  of  Skin,    Illus, 

Schamberg.    Compend.  .80 

Van   Harlingen.     Diagnosis 

and  Treatment  of  Skin  Dis. 

3d  Kd.     60  Illus.      -        -        2.7j 

SURGERY  AND  SURGICAL 
DISEASES, 

Berry.     Thyroid  Gland.      -     

Butlin.  Surgery  of  Malignant 

Disease.         -  .        -        4,50 

Cripps.    (Jvariotomy  and  Ab- 
dominal Surgery.       -        .      8,00 
Deaver.     Appendicitis.        -    3,50 

Surgical  Anatomy,     -  21,00 

Dulles,  Emergencies.  -  i.oo 
Hamilton,  Tumors,  3d  Ed.  1,25 
Heath's  .Minor,    I'thEd, 

Diseases  of  Jaws. 

Horwitz,  Compend.  5th  Ed, 
Jacobson,  Operations  of,  - 
Lane,     Surgery  of  Head, 


Blackburn.     Autopsies, 
Coplin,    Manual  of    3d  Ed. 
Da  Costa,    The  Blood, 
Thayer,     Compend,    Illus, 
Virchow,     Post-mortems. 
Whitacre.    Lab.  Text-book, 

PHARMACY 
Beasley's  Receipt-Book, 

Konnulary, 

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i    1    '■ 


SECOND  EDITION,  JUST  READY 


TYSON'S  Practice  of  Medicine 


A  TEXT-BOOK  FOR  PRACTITIONERS  AND  STUDENTS 


WITH  SPECIAL  REFERENCE  TO  DIAGNOSIS  AND  TREATMENT 


By  JAMES  TYSON,  M.D. 

Professor  of  Mtdieine  in  the  University  of  Pennsylvania  :   Physician  to  the  University  and 

Philadelphia  Hospitals,  etc. 


Mil 


COLORED  PLATES  AND  J25  OTHER  ILLUSTRATIONS 
Octavo.     1222  Pages.    Cloth,  $5.50;  Leather,  $6.50 ;  Half  Russia,  $7.50 


The  object  of  this  book  is — first,  to  aid  the  student  and  physician  to  recognize 
disease,  and,  second,  to  point  out  the  proper  methods  of  treatment.  To  this  end 
Diagnosis  and  Treatment  receive  special  attention,  while  pathology  and 
morbid  anatomy  have  such  considenuion  as  is  demanded  by  their  importance  as  funda- 
mental conditions  of  a  thorough  understanding  of  disease.  Dr.  Tyson's  qualifications 
for  writing  such  a  work  are  unecjualed.  It  is  really  the  outcome  of  over  thirty 
years'  experience  in  teaching  and  in  private  and  hospital  practice.  As  a 
teacher  he  has,  while  devoting  himself  chiefly  to  clinical  medicine,  occupied  several 
important  chairs,  notably  those  of  General  Pathology  and  Morbid  Anatomy,  and 
Clinical  Medicine  in  the  University  of  Pennsylvania,  an  experience  that  has  necessarily 
widened  his  point  of  view  and  added  weight  to  his  judgment.  This,  the  Second, 
Edition  has  been  most  thoroughly  revised,  parts  have  been  rewritten,  new 
material  and  illustrations  have  been  added,  and  in  many  respects  it  may  be  considered 
a  new  book. 

"  It  is  in  the  writing  and  prep^uation  of  a  work  of  this  cliaracter  tliat  Dr.  Tyson  stands  pre- 
eminent. Those  of  tiiL"  i)r()fessi(in — ami  lliere  are  many  at  this  time — who  have  been  fortunate  to 
have  been  his  pupils  during  tlieir  medical  student  days,  will  remember  that  he  broitglit  to  liis 
lectures  and  to  his  writings  an  amount  of  industry  and  care  which  many  otiier  teachers  failed  to 
bring;  and  those  who  know  him  best  as  an  author  and  teacher  have  expected  that  his  book  on  the 
Practice  of  Medicine,  when  ii  appeared,  would  be  a  credit  to  himself,  and  would  increase  his 
reputation  as  a  medical  author.     This  lielief  has  proved  correct." —  Thernpeutii:  Gazette^  Detroit,  Muh. 

"  After  a  third  of  a  century  spent  in  the  assiduous  study,  practice,  and  teaching  of  medicine, 
and  the  publication  of  successful  liooks  on  various  topics,  theoretical  and  practical,  the  writing  of  a 
textbook  is  not  only  a  proper  ambition,  but  is  really  expected  by  students  and  the  profession.  .So 
Professor  Tyson  best  sliows  his  modesty  by  making  no  apology  for  the  present  work." — Amtrican 
Journal  of  MeUiail  Sciftues,  Philadelphia. 


JUlLt-^JUjU-l. ^-i. 


All  prices  are  net.    No  discount  can  be  allowed  retail  purchasers. 


ill 


)ICINE 

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rstty  and 


IS 


ussia,  $7.50 


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To  this  end 
pathology  and 
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cupied  several 
Anatomy,  and 
las  necessarily 
f  the  Second, 
rewritten,  new 
be  considered 


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leen  fortunate  to 
L-  brought  to  his 
;achers  failed  to 
:  his  i)ook  on  the 
luld  increase  his 
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ng  of  medicine, 

the  writing  of  a 

profession.     So 

rk." — Amtrkan 


P.  BLAKISTON'S  SON  &  CO.'S 

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\\ 


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at,  St.  Bartholomew's  Hospital,  London,   etc.,   assisted  by  James  Berry,  f. r.c.s., 

W.M.   BkUCF.-ClARKE,   M.B.,   F.R.C.S.,  A.    H.  G.   DORAN,   F.R.C.S.,   PERCY  FURNIVALL, 

F. R.C.S.,  W.  H.  H.  Jessop,  M.B.,  F.R.c  s.,  and  H.  J.  Waring,  b.Sc,  f. r.c.s. 
Second  Ed.,  Revised  and  Rewritten.       Illus.      Just  Ready.      Octavo.      Cloth,  54- 50 

Byford.     Manual  of  Gynecology.     341  Illustrations. 

A  Practical  Student's  Book.  By  Henry  T.  Byford,  ,m.d.,  Professor  of  Gynecology 
and  Clinical  Gynecology  in  the  College  of  Physicians  and  Surgeons  of  Chicago  ; 
Professor  of  Clinical  Gynecology,  Women's  Medical  School  of  Northwestern  Uni- 
versity, and  in  Post-Graduate  Medical  School  of  Chicago,  etc.  Second  Edition, 
Enlarged.  With  341  Illustrations,  many  of  which  are  from  original  drawings  and 
several  of  which  are  Colored.      i2mo.      596  pages.  Cloth,  53.00 

Caldwell.     Chemical  Analysis. 

Elements  of  Qualitative  and  Quantitative  Chemical  Analysis.  By  G.  C.  C.\ldwi:i.i,, 
n.s.,  Ph.D.,  Professor  of  Agricultural  and  Analytical  Chemistry  in  Cornell  Univer- 
sity, Ithaca,  New  York,  etc.     Third  Edition,  Revised  and  Enlarged.     Octavo. 

Cloth,  51 -oo 

Cameron.     Oils  and  Varnishes. 

A  Practical  Handbook.     By  James  Cameron,  f.i.C.     With  Illustrations,   Formuhc, 


Tables,  etc.      121110. 

Soap  and  Candles. 

A  Handbook  for  Manufacturers,  Chemists,  Analysts,  etc. 


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54  Illustrations.     i2mo. 
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spital,  London. 

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Carpenter.     The  Microscope  and  Its  Revelations. 
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F.R..S.     Revised    and    Enlarged,    with    800    Illustrations    and    many    Lithographs. 
Octavo.  Nearly  Ready. 

Cazeaux  and  Tarnier's  Midwifery.     With  Appendix,  by  Munde. 

The  Theory  and  Practice  of  Obstetrics,  including  the  Diseases  of  Pregnancy  and 
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and  revised  by  S.  Tarnier,  m.d.  Eighth  American  from  the  Eighth  French  and 
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The  Newer  Remedies. 

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Octavo.  Cloth,  51.00 

Volumetric  Analysis. 

A  Practical  Handbook  for  Students  of  Chemistry.     Illustrated.     8vo.     In  Press. 

Cohen.     System  of  Physiologic  Therapeutics..     Illustrated. 

A  Practical  Exposition  of  the  Methods  Other  than  Drug-giving,  Useful  in  the  Treat- 
ment of  the  Sick.  Edited  by  Solomon  Solis  Cohen,  a.m.,  m.d..  Professor  of 
Medicine  and  Therapeutics  in  the  Philadelphia  Polyclinic  ;  Lecturer  on  Clinical 
Medicine  at  Jefferson  Medical  College  ;  Physician  to  the  Philadelphia  and  Rush  Hos- 
pitals ;  formerly  Lecturer  on  Therapeutics,  Dartmouth  Medical  College.  To  be 
issued  in  Eleven  Compact  Octavo  Volumes.        Price  for  Set  Complete,  Cloth,  522.00 

Electrotherapy.     Illustrated.     Two  Volumes. 

By  George  W.  Jacoby,  m.d..  New  York,  Consulting  Neurologist  to  the  German 
Hospital,  to  the  Infirmary  for  Women  and  Children,  to  the  Craig  Colony  for 
Epileptics,  etc.  Special  articles  by  Edward  Jackson,  a.m.,  m.d.,  Denver, 
Col. ;  Emeritus  Professor  of  Diseases  of  the  Eye  in  the  Philadelphia  Polyclinic  ; 
Member  American  Ophthalmological  Society  ;  Fellow  and  ex-President  American 
Academy  of  Medicine,  etc. — By  William  Sciiei'PE(;kell,  .m.d..  New  Orleans, 
Member  American  Laryngological,  Rhinological,  and  Otological  .Society. — 
By  J.  Chalmers  Da  Costa,  m.d..  Clinical  Professor  of  Surgery  in  Jefferson 
Medical  College  ;  Surgeon  to  the  Philadelphia  and  to  St.  Joseph's  Hospitals, 
etc. — By  Franklin  H.  Martin,  m.d..  Professor  of  Gynecology,  Post-Graduate 
Medical  School  of  Chicago  ;  Gynecologist  Chicago  Charity  Hospital  ;  Chairman 
Section  of  Obstetrics  and  Diseases  of  Women  of  the  American  Medical  Asso- 
ciation (1895),  etc.  By  A.  H.  Ohmanx-Dumesnil,  m.d..  Editor  .S7.  Louis 
Medical  and  Surgical  Journal ;  Member  International  Dcrniatological  Congress  ; 
formerly  Professor  of  I)ermatology,  St.  Louis  Medical  College,  etc. 


I 


10 


p.  BLAKISTON'S  SON  6-  CO.'S 


Cohen,     Physiologic  Therapeutics. — Continued. 

Climatology  and   Health   Resorts,   Including   Mineral   Springs. 

Two  Volumes,  with  Maps. 

By  F.  Parkes  Weber,  m.a.,  m.d,,  f.r.c.p.  (Lond.),  Physician  to  the  German 
Hospital,  Dalston  ;  Assistant  Physician  North  London  Hospital  for  Consump- 
tion ;  Author  of  " The  Mineral  Waters  and  Health  Resorts  of  Europe;"  and 
Guv  Hinsdale,  a.m.,  m.d.,  Secretary  of  the  American  Climatological  Associa- 
tion ;  President  of  the  Pennsylvania  Society  for  the  Prevention  of  Tuberculosis  ; 
formerly  Lecturer  on  Medical  Climatology  in  the  University  of  Pennsylvania,  etc. 

Prophylaxis — Personal  Hygiene — Care  of  the  Sick.     Illustrated. 

By  Harold  C.  Ernst,  m.d.,  Professor  of  Bacteriology  in  the  Medical  School  of 
Harvard  University,  Boston  ;  and  Albert  Abrams,  m.d.  (University  of  Heidel- 
berg), formerly  Professor  of  Pathology,  Cooper  Medical  College,  San  Francisco. 

Dietotherapy.     Food  in  Health  and  Disease. 

By  Nathan  S.  Davis,  Jr.,  a.m.,  m.d.,  Professor  of  Principles  and  Practice  of 
Medicine  in  Northwestern  University  Medical  School  ;  Physician  to  Mercy  Hos- 
pital, Chicago  ;  Member  American  Academy  of  Medicine,  American  Climato- 
logical Society,  etc. 

Mechanotherapy.  Illustrated. 
By  John  Kearsley  Mitchell,  m.d..  Assistant  Physician  to  the  Orthopedic 
Hospital  and  Infirmary  for  Nervous  Diseases  ;  Assistant  Neurologist  Presbyterian 
Hospital,  Philadelphia ;  Attending  Physician  to  the  Pennsylvania  School  for 
Feeble-minded  Children  ;  Fellow  College  of  Physicians  of  Philadelphia,  etc. , 
formerly  Lecturer  on  Symptomology  at  the  University  of  Pennsylvania  ;  and 
Luther  Gulick,  m.d.,  of  Brooklyn,  N.  Y.,  formerly  of  Springfield,  Mass.,  Mem. 
American  Association  for  Advancement  of  Physical  Education,  Amer.  Medical 
Association,  etc. 

Rest — Mental  Therapeutics — Suggestion. 

By  Francis  X.  Dercum,  m.d.,  Clinical  Professor  of  Nervous  Diseases  in  Jeffer- 
son Medical  College ;  Neurologist  to  the  Philadelphia  Hospital ;  Consulting' 
Physician  to  the  State  Asylum  for  the  Chronic  Insane  at  Wernersville,  Penna. ; 
Consulting  Neurologist  to  St.  Agnes'  Hospital ;  Neurologist  to  the  Jewish  Hos- 
pital of  Philadelphia. 

Hydrotherapy — Thermotherapy — Balneology — Phototherapy. 

By  Dr.  Wilhelm  Winternitz,  Professor  of  Clinical  Medicine  in  the  University 
of  Vienna  ;  Director  of  the  General  Polyclinic  in  Vienna,  etc. ;  and  Dr.  E. 
Heinrich  Kisch,  Professor  in  the  University  of  Prague  ;  Physician  at  Marien- 
bad  Spa. 

Pneumatotherapy  and  Inhalation  Methods.     Illustrated. 

By  Dr.  Paul  Tissier,  Chief  of  Clinic  of  the  Faculty  of  Medicine  of  Paris. 

Serotherapy — Organotherapy — Blood-Letting,  etc. — Principles  ol 
Therapeutics — Digest — I  ndex. 

By  Josei'H  McFarland,  m.d.,  Professor  of  Pathology  in  the  Medico-Chirurgical 
College,  Philadelphia  ;  Pathologist  to  the  Medico-Chirurgical  Hospital  and  to  the 
Rush  Hospital  for  Consumptives  and  Allied  Diseases,  etc. — O.  T.  Osborne, 
m.d..  Professor  of  Materia  Medica  and  Therapeutics,  Medical  Department,  Yale 
University,  New  Haven. — Frederick  A.  Packard,  m.d..  Visiting  Physician  to 
the  Pennsylvania  and  to  the  Children's  Hospitals. — The  Editor,  and  Augustis 
A.  EsHNER,  M.D.,  Professor  of  Clinical  Medicine  in  the  Philadelphia  Polyclinic  ; 
Physician  to  the  Philadelphia  Hospital,  etc. 

*„*  Complete  descriptive  circular  upon  application. 


w.irtiKtrWmwrawniWffrrt'i'iifflw 


? 


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;ral   Springs. 

to  the  German 
1  for  Consump- 

Europe ;"  and 
logical  Associa- 
)f  Tuberculosis  ; 
nnsylvania,  etc. 

Illustrated. 

edical  School  of 
is^ty  "f  Heidcl- 
San  Francisco. 


ind  Practice  of 
to  Mercy  Hos- 
lerican  Climato- 


the  Orthopedic 
jist  Presbyterian 
ania  School  for 
iladelphia,  etc. , 
msylvania  ;  and 
Id,  Mass.,  Mem. 

Amer.  Medical 


iseases  in  Jeffer- 
tal  ;  Consulting' 
ersville,  Penna.; 
he  Jewish  Hos- 

totherapy. 

n  the  University 
;. ;  and  Dr.  P:. 
ician  at  Marien 

ted. 

le  of  Paris. 

Principles  ol 

iico-Chirurgical 
pital  and  to  the 

.   T.    OSIIORNE, 

;partment,  Yale 

ng  Physician  to 

and  AuGUSTi's 

hia  Polyclinic  ; 


Cohen.     The  Throat  and  Voice. 
By  J.  Sous  Cohen,  M.n.     Illustrated.     i2mo.  Cloth,  .40 

Congdon.     Laboratory  Instructions  in  General  Chemistry. 

By  Ernkst  a.  Congdon,  Professor  of  Chemistry  in  the  Drexel  Institute,  Philadelphia  ; 
Member  American  Chemical  Society  ;  Fellow  of  the  London  Chemical  Society,  etc. 
With  an  Appendix,  useful  Tables,  and  56  Illustrations.  Interleaved,  Cloth,  5i-oo 

Conn,     Agricultural  Bacteriology. 

Including  a  Study  of  Bacteria  as  Relating  to  Agriculture,  with  Special  Reference  to 
the  Bacteria  in  Soil,  in  the  Dairy,  in  Food  Products,  in  Domestic  Animals,  and  in 
Sewage.  By  H.  \V.  Conn,  Ph.D.,  Professor  of  Biology,  Wesleyan  University, 
Middletown,  Conn. ;  Author  of  "  Evolution  of  To-day,"  "  The  Story  of  Germ  Life," 
etc.     With  Illustrations.  In  Press. 

Cooper.     Syphilis.     Colored  Plate. 

By  Alfred  Cooper,  f.r.c.s..  Senior  Surgeon  to  St.  Mark's  Hospital ;  late  Surgeon 
to  the  London  Lock  Hospital,  etc.  Second  Edition,  Edited  by  Edward  Cot- 
TERELL,  F.R.C.S.,  Surgeon  London  Lock  Hospital,  etc.  20  Full-page  Plates  contain- 
ing many  Colored  Figures.     Octavo.  Cloth,  $5.00 

Coplin.     Manual  of  Pathology.     Third  Edition.     330  Illustrations. 

Including  Bacteriology,  the  Technic  of  Post-mortems,  and  .Methods  of  Pathologic 
Research.  By  W.  M.  Late  Coplin,  m.d..  Professor  of  Pathology  and  Bacteriology, 
Jefferson  Medical  College  ;  Pathologist  to  Jefferson  Medical  College  Hospital  and  to 
the  Philadelphia  Hospital ;  Bacteriologist  to  the  Pennsylvania  State  Board  of  Health. 
Third  Edition,  Rewritten  and  Enlarged.  330  Illustrations,  many  of  which  are  origi- 
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Practical  Hygiene. 

With  Special  Articles  on  Plumbing,  Ventilation,  etc. 
Second  Edition. 


138  Illustrations.     8vo. 
In  Preparation. 

Cripps.     Ovariotomy  and  Abdominal  Surgery. 

By  Harrison  Cripps,  f.r.c.s..  Surgical  Staff,  St.  Bartholomew's  Hospital,  London. 
With  17  Plates  and  115  other  Illustrations.     Large  Octavo.  Cloth,  $8.00 

Crocker.     Diseases  of  the  Skin. 

Their  Description,  Pathology,  Diagnosis,  and  Treatment,  with  Special  Reference  to 
the  Skin  Eruptions  of  Children.  By  H.  Radcliffe'Crocker,  m.d.,  Physician  to 
the  Department  of  Skin  Diseases,  University  College  Hospital,  London.  92  Illustra- 
tions.    Third  Edition.  Preparing. 

Cuff.     Lectures  on  Medicine  to  Nurses. 

By  Herbert  Ed.mund  Cuff,  m.d.,  late  Assistant  Medical  Officer,  Stockwell  Fever 
Hospital,  England.     Second  Edition,  Revised.     With  25  Illustrations.     Cloth,  $1.25 

Cushing.     Compend  of  Histology. 

Specially  adapted  for  the  use  of  Medical  Students  and  Physicians.  By  H.  H.  Cushing, 
m.d..  Director  of  Histological  and  Embryological  Laboratories,  Woman's  Medical 
College  of  Pennsylvania  ;  Demonstrator  of  Histology  and  Embryology,  Jefferson 
Medical  College,  Philadelphia.  Illustrated.  No.  //  .•'  Oiiiz-Coinpcnd ?  Series. 
i2mo.  Cloth,  .80;  Interleaved  for  Notes,  $1.00 

Dalby.     Diseases  and  Injuries  of  the  Ear. 

By  Sir  William  B.  Daliiv,  m.d..  Aural  Surgeon  to  St.  George's  Hospital,  London. 
Fourth  Edition.     With  38  Wood  Engravings  and  8  Colored  Plates.  Cloth,  $2.50 


I 


13 


P.  BLAKIS TON'S  SOA   6-   CO.'S 


Davis.     Dietotherapy.     Food  in  Health  and  Disease. 
See  Cohen,  Physiologic  Therapeutics,  page  lo. 

Davis,     jt^ssentials  of  Materia  Medica  and  Prescription  Writing. 

By  J.   AunREY  Davis,  m.d.,  late  Assistant  Demonstr.-itor  of  Obstetrics  and  Qui/ 
Master  in  Materia  Medica,  University  of  Pennsylvania.      i2mo.  Cloth,  Ji.;o 

Domville.     Manual  for  Nurses 

and  Others  Engaged  in  Attending  to  the  Sick.  By  F.n.  J.  Domvim.e,  m.d.  Eighth 
Edition,  Revised.     With  Recipes  for  Sick-room  Cookery,  etc.      i2mo.         Cloth,  .75 

Donders.     Refractio'       Portrait  of  Author. 

An  Essay  on  the  Nature  ,  I  the  Consequences  of  Anomalies  of  Refraction.  By  F. 
C.  Donders,  m.d,,  late  Professor  of  Physiology  and  Ophthalmology  in  the  Univer- 
sity of  Utrecht.  Authorized  Translation.  Revised  and  Edited  by  Chakle-S  A. 
Oliver,  a.m.,  m.d.  (Univ.  Pa.),  one  of  the  Attending  Surgeons  to  the  Wills  Eye 
Hospital ;  one  of  the  Ophthalmic  .Surj,'eons  to  the  Philadelphia  Hospital,  etc.  With 
a  Portrait  of  the  Author  and  a  Series  of  Explanatory  Diagrams.     Octavo. 

Half  Morocco,  Gilt,  $1.25 

Da  Costa.     Clinical  Pathology  of  the  Blood.     Colored  Plates. 

A  Practical  Guide  to  the  Examination  of  the  Blood  by  Clinical  Methods,  with  Refer- 
ence to  the  Diagnosis  of  Disease.  By  John  C.  Da  Costa,  Jr.,  m.d..  Assistant 
Demonstrator  of  Chnical  Medicine  in  the  Jefferson  Medical  College,  Philadelphia  . 
Assistant  in  the  Medical  Clinic,  Jefferson  Medical  College  Hospital ;  Htumatologist 
to  the  German  Hospital.     With  six  Colored  Plates  and  other  Illustrations.     Octavo. 

In  Prfss. 

Deaver.     Surgical  Anatomy.     400  Full-page  Plates. 

A  Treatise  on  Human  Anatomy  in  its  Application  to  the  Practice  of  Medicine  and 
Surgery.  By  John  B.  Deaver,  m.d.,  Surgeon-in-Chief  to  the  German  Hospital  ; 
Surgeon  to  the  Children's  Hospital  and  to  the  Philadelphia  Hospital ;  Consultin;^ 
Surgeon  to  St.  Agnes',  St.  Timothy's,  and  Germantown  Hospitals  ;  formerly  Assistant 
Professor  of  Apphed  Anatomy,  University  of  Pennsylvania,  etc.  With  over  401 
very  handsome  Full-page  Illustrations  engraved  from  original  drawings  made  bx 
special  artists  from  dissections  prepared  for  the  purpose  in  the  dissecting-rooms  of  1  he 
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Synopsis  of  Contents. 
-I'pper  Extremity — Back  of  Neck,  Shoulder,  and  Trunk- 


-Craniuni 


VOLU.ME  I. 

— Scalp — Face 
Volume  II. — Neck — Mouth,   Pharynx,   Larynx,   Nose — Orbit — Eyeball — Organ 

of  Hearing — Brain — Female  Perineum — Male  Perineum. 
Volume  III. — Abdominal  Wall — Abdominal   Cavity — Pelvic    Cavity — Chest — 

Lower  Extremity. 

"  In  summing  up  the  general  excellences  of  this  remarkable  work,  we  can  accord  our  unqual- 
ified praise  for  the  accurate,  exhaustive,  and  systematic  manner  in  which  the  author  lias  carried  out 
his  plan,  and  we  can  commend  it  as  a  model  of  its  kind,  which  must  be  possessed  to  be  appre- 
ciated."—  The  Me.iiciil  Record,  New  York. 

Appendicitis.     Second  Edition. 

Its  History,  Anatomy,  Etiology,  Pathology,  Symptoms,  Diagnosis,  Prognosis, 
Treatment,  Complications,  and  Sequel.v.'.  A  Systematic  Treatise,  with  22  Plates, 
ID  of  which  are  Colored,  drawn  specially  for  this  work.  Second  Edition,  Re- 
vised and  Rewritten.      8vo.     Just  Ready,  Cloth,  $3.50 


Writing. 

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iction.     By  F. 

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Dercum.     Rest — Mental  Therapeutics — Suggestion. 
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Duckworth.     On  Gout.     Illustrated. 

A  Treatise  on  Gout.  By  Sir  Dvcii  Duckworth,  m.d.  (Edin.),  f.r.c.p.,  Physician  to, 
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Taylor,  k.r.c.s.,  Sur;.'eon  to  the  Birmingham  and  Midlands  Hospital  for  Women  ; 
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Ernst.     Prophylaxis — Personal   Hygiene — Nursing  and  Care  of  the 
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Gould.      The    Illustrated    Dictionary    of    Medicine,    Biology,    and 
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The  Student's  Medical  Dictionary.     B^levcnth  Ed.     Illustrated. 

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System.     261  Illustrations. 

By  H.  C.  Gordinier,  a.m.,  m.d..  Professor  of  Physiology  and  of  the  Anatomy  of 
the  Nervous  System  in  the  Albany  Medical  College  ;  Member  American  Neurological 
Association.  With  48  Full-pajje  Plates  and  213  other  Illustrations,  a  number  of 
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anatomy,  and  dry  enough  they  ;\re,  as  we  all  remember  only  too  well;  but  the  anatomy  of  tin 
nervous  system  alone  is  another  m:itter  entirely,  for  it  is  one  of  the  most  interesting  of  all  subjects 
of  medical  study  at  the  s.nme  time  that  it  is  one  of  the  most  diffiiult.  For  both  of  these  reasons 
the  subject  is  deserving  of  a  treatise  by  itself,  and  .should  not  be  briefly  discussed  in  a  few  pages  of 
a  general  work  on  anatomy  or  in  an  introductory  chapter  of  a  treatise  on  diseases  of  the  nervous 
system." — The  Neiv  York  Medical  Rfcoril. 

Gorgas'  Dental  Medicine, 

A  Manual  of  Materia  Medica  and  Therapeutics.  By  Ferdinand  J.  S.  Gorgas,  m.d., 
D.  D.s. ,  Professor  of  the  Principles  of  Dental  Science,  Oral  Surgery,  and  Dental 
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erature. 

chiefly  Irotn  the 
est  manner,  ihc 
It  the  same  time 
Lilly  shown,  they 

and  enable  the 
1  borrowed  from 
he  general  style 

in  details  \.'hich 

s  the  thanks  of  the 
enough  oa  general 
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the  Brain,  Kidney,  etc.  Third  Edition,  Revised,  with  the  assistance  of  R. 
Marcus  Gijnn,  f.r.c.s..  Surgeon  Royal  London  Ophthalmic  Hospital,  Moor- 
fields.     Octavo.  Cloth,  $4.00 

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A  Volume  of  Essays  on  the  Diagnosis,  Treatment,  etc.,  of  Diseases  of  the 
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Epilepsy  and  Other  Chronic  Convulsive  Diseases. 

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Haig.     Causation  of  Disease  by  Uric  Acid.     Fifth  Kdition. 

A  Contribution  to  the  Pathology  of  High  Arterial  Tensioi:,  Headache,  Epilepsy, 
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Diet  and  Food. 

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Hall.     Diseases  of  the  Nose  and  Throat. 

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Hansell  and  Reber.     Muscular  Anomalies  of  the  Eye. 

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26 


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32 


P.  BLAK/STON'S  SON  <S-  CO.'S 


I 


,1 

II 


1 


Schreiner.     Diet  List. 

Arranged  in  the  Form  of  a  Chart  on  which  Articles  of  Diet  can  be  Indicated  for  any 
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Scott.     The  Urine  :  Its  Chemical  and  Microscopical  Examination. 

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Scoville.     The  Art  of  Compounding.     Second  Edition. 
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Sheild.     Lectures  on  Nasal  Obstruction. 

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Shuttleworth.     Mentally  Deficient  Children. 

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Smith.     Abdominal  Surgery.     Sixth  Edition. 

Being  a  Systematic  Description  of  all  the  Principal  Operations.  By  J.  Greig  Smith, 
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Smith.     Electro-Chemical  Analysis. 

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Smith  and  Keller.     Experiments. 

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Sc.d.,  Professor  of  Chemistry,  University  of  Pennsylvania,  and  Dr.  H.  F.  Keller, 
lVof':ssor  of  Chemistry,  Philadelphia  High  School.  Fourth  Revised  Edition.  8vo. 
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Smith.     Dental  Metallurgy. 

A  Manual.  By  Ernest  A.  Smith,  f.c.s..  Assistant  Instructor  in  Metallurgy,  Royal 
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Smith.     Wasting  Diseases  of  Infants  and  Children. 

By  Eustace  Smith,  m.d.,  f.r.c.p..  Physician  to  the  East  London  Hospital  for 
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Stirling.     Outlines  of  Practical  Physiology. 

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Outlines  of  Practical  Histology. 

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Stohr.       Text-Book   of    Histology,    Including   the    Microscopical 

Technic.     301  Illustrations. 

By  Dr.  Philip  Stohr,  Professor  of  Anatomy  at  University  of  Wiirzburg.  Author- 
ized Translation  by  Emma  L.  Bii-stein,  m.u.,  formerly  Demonstrator  of  Histology, 
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ScHAPER,  Professor  of  Anatomy,  University  of  Rreslau;  formerly  Demonstrator  of 
Histology,  Harvard  Medical  School,  Boston.  Third  American  from  the  Eighth  German 
Edition,  Enlarged  and  Revised.     301  Illustrations.     Octavo.  Cloth,  J3.CX) 

"This  edition  of  an  already  well-known  student's  manual  requires  little  but  favorable  com- 
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Sturgis.     Manual  of  Venereal  Diseases.     Seventh  Edition. 

By  F.  R.  Sturgis,  m.d..  Sometime  Clinical  Professor  of  Venereal  Diseases  in  the 
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Sutton's  Volumetric  Analysis. 

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raphy, etc.,  and  for  the  Valuation  of  Substances  Used  in  Commerce,  Agriculture, 
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With  116  Illustrations.     8vo.     Just  Ready.  Cloth,  $5.00 

Swain.     Surgical  Emergencies. 

Together  with  the  Emergencies  Attendant  on  Parturition  and  the  Treatment  of  Poison- 
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Swanzy.     Diseases  of  the  Eye  and  their  Treatment. 

A  Handbook  for  Physicians  and  Students.  By  Henry  R.  Swanzy,  a.m.,  m.b., 
F.R.C.S. I.,  Examiner  in  Ophthalmology,  University  of  Dublin  ;  Surgeon  to  the  National 
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Symonds.     Manual  of  Chemistry 
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Tanner's  Memoranda  of  Poisons 

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Taylor.     Practice  of  Medicine. 

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86 


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Tissier.     Pneumatotherapy  and  Inhalation  Methods. 
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Tomes'  Dental  Anatomy. 

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Mental  Disorders,  together  with  the  Law  of  Lunacy  in  Great  Britain  and  Ireland. 
Edited  by  D.  Hack  Tuke,  m.d.,  ll.d.,  Examiner  in  Mental  Physiology  in  the  Uni- 
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Traube.     Physico-Chemical  Methods. 

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Thresh.     Water  and  Water  Supplies. 

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WRITING.     Sixth  Revi=ed  Edition.     .Same  author  as  No.  I.  ; 

,7.     GYNECOLOGY.     Second  Edition.     By  Wm.  H.  Wells,  m.d..  Instructor  of  Oistct- 
rics,  Jefierson  Medical  College,  Philadelphia.      140  Illustrations. 

8.  DISEASES  OF  THE  EYE  AND  REFRACTION.  Second  Edition.  Incaid 
ing  Treatment  and  Surgery  and  a  Section  on  Local  Therapeutics.  By  George  M.  Gt)U..l), 
M.I).,  Editor  Philadelfhia  Mediial  Journal,  anA  VV.  L.  Pyi.e,  M.D. ,  Assistant  .'■'urgeon,  Wills 
Eye  Hospital.  With  l-'ormuUc,  Glossary,  several  useful  Tables,  and  109  Illustrations. 
,  9.  SURGERY,  Minor  Surgery,  and  Bandaging.  Fifth  Edition,  Enlarged  and  In  - 
proved.  By  GrviL'.  :.  HoRwrrz,  B.s.,  m.d.,  Clinical  Professor  of  Genito- Urinary  Surgery 
and  Venereal  Disea-es  in  Jefferson  Medical  College  ;  Surgeon  to  Philadelphia  Hospital,  etc. 
With  98  Poiniula;  arid  167  Illustrations. 

No.  10.  MEDICAL  CHEMISTRY.  Fourth  Edition.  Including  Urinalyfis,  Chemistr>'  of 
Milk,  Blood,  etc.  iiy  Henry  LeffMANN,  m.d..  Professor  of  Chemistry  in  Pennsylvania 
College  of  Dental  Surgery  and  in  the  Woman's  Medical  College,  Philadelphia. 

No.  II.  PHARMACY.  Fifth  Edition.  Based  upon  Professor  Remington's  Text-Book  of 
Pharmacy.  By  F.  E.  Stewart,  m.d.,  PH.c,  late  (^uiz-Masler  in  Pharmacy  and  Chemistry, 
Philadelphia  College  of  Pharmacy;   Lecturer  at  Jefferson  Medical  College. 

No.  12.  VETERINARY  ANATOMY  AND  PHYSIOLOGY.  Illustrated.  By  Wm. 
R.  Bam.ou,  m.d.,  Professor  of  Equine  Anatomy  at  New  Vork  College  of  Veterinary  Sur- 
geons;  1  hysician  to  Bellevue  Dispensary,  etc.     With  29  graphic  Illustrations. 

No.  13.  DENTAL  PATHOLOGY  AND  DENTAL  MEDICINE.  Third  Edition, 
Illustrated..   By  George  W.  Warrkn,  D.d.s.,  Pennsylvania  College  of  Dental  .Surgery. 

No.  14.  DISEASES  OF  CHILDREN.  Colored  Plate.  By  MARns  P.  Hatfield, 
Professor  of  Diseases  of  Children,  Chicago  Medical  College.      Second  Edition,  Enlarged. 

No.  15.     GENERAL  PATHOLOGY.  Illustrated.    By  A.  E.  Tiiayer,  m.d.,  etc.   Preparins^. 

No.  16.  DISEASES  OF  THE  SXIN.  By  Jay  F.  .Siiiamhkrg,  m.d.  Professor  of  Skin 
Diseases,  Philadelphia  Polyclinic.      Second  Edition,  Revised.     105  Illustrations. 

No.  17.     HISTOLOGY.     Illustrated.     B)  II.  H.  Cushing,  m.u.  Preparing. 

4» 


No. 


No. 


No. 


No. 


JUST  READY,  ONEJ/OLUME 

A  Cyclopedia  of  Practical 
Medicine  and  Surgery 

A  CONCISE  REFERENCE  BOOK,  ALPHABETICALLY 

ARRANGED 

OF 

MEDICINE,  SURGERY,  OBSTETRICS,  MATERIA  MEDICA,  THERAPEUTICS, 

AND  THE  VARIOUS  SPECIALTIES,  WITH  PARTICULAR 

REFERENCE  TO  DIAGNOSIS  AND  TREATMENT 

COMPILED  UNDER  THE  EDITORIAL  SUPERVISION  OF 

GEORGE  M.  GOULD,  M.D.   AND   WALTER  L.  PYLF,  M.D. 


Author  of  "An  Illustrated  Dictionary  of  Medicine  | " 
Editor  "  Philadelphia  Medical  Journal,"  etc. 


Assistant  Surgeon  Wills  Eye  Hospital)  formerly 
Editor  "  International  Medical  Magazine,"  etc. 


AND  SEVENTY-TWO  SPEQAL  CONTRffiUTORS 


WITH  MANY  ILLUSTRATIONS 


LARGE  SQUARE  OCTAVO.  TO  CORRESPOND  ^XaTH  GOULD'S  "  ILLUSTRATED 
DICTIONARY."  FULL  SHEEP  OR  HALF  DARK-GREEN  LEATHER,  JJO.OOi 
WITH    THUMB   INDEX,    $H.00»      HALF   RUSSIA,   THUMB  INDEX,   $  J  2.00,   NET 

The  great  success  of  Dr.  Gould's  "  Illustrated  Dictionary  of  Medicine  "  suggested 
the  preparation  of  this  companion  volume,  which  should  be  to  the  physician  the  same 
trustworthy  handbook  in  the  broad  field  of  general  information  that  the  Dictionary  is 
in  the  more  special  one  of  the  explanation  of  words  and  the  statement  of  facts.  The 
aim  has  been  to  provide  in  a  one-volume  book  all  the  material  usually  contained  in 
the  large  systems  and  much  which  they  do  not  contain.  Instead  of  long  discursive 
papers  on  special  subjects  there  are  short,  concise,  pithy  articles  alphabetically 
arranged,  giving  the  latest  methods  of  diagnosis,  treatment,  and  operating — a  working 
book  in  which  the  editors  and  their  collaborators  have  condensed  all  that  is  essential 
from  a  vast  amount  of  literature  and  personal  experience. 

The  illustrations  have  been  selected  with  care,  only  those  having  been  used  that  are 
of  practical  value  ;  no  effort  has  lieen  made  to  overload  the  book  with  useless  pictures. 

The  seventy-two  special  contributors — the  names  of  whom  are  given  on  the 
following  page — have  been  selected  from  all  parts  of  the  '~ountry  in  accordance 
with  their  fitness  for  treating  special  suljjects  about  which  they  may  be  considered 
expert  authorities.  They  are  all  men  of  prominence,  teachers,  investigators,  and 
writers  of  experience,  who  give  to  the  book  a  character  unequaled  by  any  other  work 
of  the  kind. 


4a 


ICAL 
Y 

STICALLY 


GOULD  AND  PYLE'S 

CYCLOPEDIA  OF  MEDICINE 


LIST   OF  CONTRIBUTORS 


SRAPEXJTICS, 
JLAR 


YLE,  M.D. 

e  Hospital »  formerly 
ical  Magazine,"  etc. 


ORS 


-USTRATED 
ER,  $10.00 1 
M2.00,   NET 

:ine"  suggested 
I'sician  the  same 
le  Dictionary  is 
:  of  facts.  The 
lly  contained  in 

long  discursive 
3  alphabetically 
ing — a  working 

that  is  essential 

en  used  that  are 
useless  pictures. 
E  given  on  the 
in  accordance 
■  be  considered 
'estigators,  and 
any  other  work 


noN 


Samuel  W.  Abbott,  A.M.,  M.D.,  Boston. 

James  M.  Anders,  M.D.,  LL.D.,  Pbila. 

Joseph  D.  Bryant,  M.D.,  New  York. 

James  B.  Bullitt,  M.D.,  Louisville. 

Charles  H.  Burnett,  A.M.,  M.D.,  Phila. 

J.  Abbott  Cantrell,  M.D.,  Philadelphia. 

Archibald  Church,  M.D.,  Chicago. 

L.  Pierce  Clark,  M.D.,  Sonyea,  N.  Y. 

Solomon  Solis-Cohen,  M.D.,  Philadelphia. 

Nathan  S.  Davis,  Jr.,  M.D.,  Chicago. 

Theodore  Diller,  M.D.,  Pittsburg. 

Augustus  A.  Eshner,  M.D.,  Philadelphia. 

J.  T.  Eskridge,  M.D.,  Denver,  Col. 

J.  McFadden  Gaston,  A. B.,  M.D.,  Atlanta, 
Ga. 

J.  McFadden  Gaston,  Jr.,  A.M.,  M.D.,  At- 
lanta, Ga. 

Virgil  P.  Gibney,  M.D.,  New  York. 

George  M.  Gould,  A.M.,  M.D.,  Phila. 

W.  A.  Hardaway,  A.M.,  M.D.,  St.  Louis. 

John  C.  Hemmeter,  M.S.,  M.D.,  Baltimore. 

Barton  Cooke  Hirst,  M.D.,  Philadelphia. 

Bayard  Holmes,  M.D.,  Chicago. 

Orville  Horwitz,  B.S.,  M.D.,  Philadelphia. 

Daniel  E.  Hughes,  M.D.,  Philadelphia. 

James  Nevins  Hyde,  A.M.,  M.D.,  Chicago. 

E.  Fletcher  Ingals,  A.M.,  M.D.,  Chicago. 

Abraham  Jacobi,  M.D.,  New  York. 

William  W.  Johnston,  M.D.,  Washington, 
D.  C. 

Wyatt  Johnston,  M.D.,  Montreal. 

Allen  A.  Jone /,  M.D.,  Buffalo. 
William  W.  Keen,  M.D.,  LL.D.,  Phila. 
Howard  S.  Kinne,  M.D.,  Philadelphia. 
Ernest  Laplace,  M.D.,  Philadelphia. 
Benjamin  Lee,  M.D.,  Philadelphia. 
Charles  L.  Leonard,  M.D.,  Philadelphia. 
James  Hendrie  Lloyd,  A.M.,  M.D.,  Phila. 
J.  W.  MacDonald,  M.D.  (Edin.),  F.R.C.S. 

Ed.,  Minneapolis. 
L.  S.  McMurtry,  M.D.,  Louisville. 
G.  Hudson  Makuen,  Philadelphia. 

43 


Matthew  D.  Mann,  M.D.,  Buffalo. 

Henry    O.    Marcy,   A.M.,    M.D.,    LL.D., 
Boston. 

Rudolph  Matas,  M.D.,  New  Orleans. 

Joseph  M.  Mathews,  M.D.,  Louisville. 

John  K.  Mitchell,  M.D.,  Philadelphia. 

Harold  N.  Moyer,  M.D.,  Chicago. 

John  H.  Musser,  M.D.,  Philadelphia. 

A.  G.  NichoUs,  M.D.,  Montreal. 

A.  H.     Ohmann-Dusmesnil,     M.D.,     St, 
Louis. 

William  Osier,  M.D.,  Baltimore. 

Samuel   O.    L.  Potter,  A.M.,  M.D.,  M.R. 

C.P.  (London),  San  Francisco. 
Walter  L.  Pyle,  A.M.,  M.D.,  Philadelph-a. 

B.  Alexander  Randall,  A.M.,  M.D.,  Phila. 
Joseph  Ransohoff,  M.D.,  F.R.C.S.  (Eng.), 

Cincinnati. 
Jay  F.  Schamberg,  A.M.,  M.D.,  Phila. 
Nicholas  Senn,  M.D.,  LL.D.,  Chicago. 
Richard  Slee,  M.D.,  Swiftwater,  Pa. 
S.    E.    Solly,   M.D.,    M.R.C.S.,    Colorado 

Springs,  Col. 
Edmond  Souchon,  M.D.,  New  Orleans. 
Ward  F.  Sprenkel,  M.D.,  Philadelphia. 
Charles  G.  Stockton,  M.D.,  Buffalo. 
John  Madison  Taylor,  A!M.,  M.D.,  Phila. 
William  S.  Thayer,  M.D.,  Baltimore. 
James  Thorington,  A.M.,  M.D.,  Phila. 
Martin  B.  Tinker,  M.D.,  Philadelphia. 
James  Tyson,  M.D.,  Philadelphia. 
J.  Hilton  Waterman,  M.D.,  New  York. 
H.  A.  West,  M.D.,  Galveston,  Texas. 
J.  William  White,  M.D.,  PH.D.,  Phila. 
Reynold  W.  Wilcox,  M.A.,  M.D.,  LL.D., 

New  York. 
George  Wilkins,  M.D.,  Montreal. 
DeForest  Willard,  M.D.,  Philadelphia. 
Alfred  C.  Wood,  M.D.,  Philadelphia. 
Horatio  C.  Wood,  M.D.,  LL.D.,  Phila. 
Albert  Woldert,  PH.G.,  M.D.,  Phila. 
James  K.  Young,  M.D.,  Philadelphia. 


Deaver's  Surgical  Anatomy 


A  Treatise  on  Human  Anatomy 
in  its  Application  to  the  Practice 
of  Medicine  and  Surg;ery    ^     J^ 

By  JOHN  B.  DEAVER,  M.D. 

Surgton-in-Chief  to  the  Girman  Hospital,  Philadelfihia ;  Surgeon  to  the  Children'!  Hospital; 
Consulting  Surgeon    to   St.  Agnes',  St.    Timothy's,    and  Germantown 
Hospitals :  formerly  Assistant  Pro/issor  o/  Applied   < 
Anatomy,  University  of  Pennsylvania,  etc. 

In  Three  Royal  Octavo  Volumes,  containing  about  Four  Hundred  and  Fifty  Full-page  Plates, 
nearly  all  from  dissections  made  for  the  purpose 


m. 


Handsome  Cloth,  Sai.oo ;    Full  Sheep,  $14.00  ;    Half  Qreen  Morocco, 
Marbled  Edges,  $34.00 ;  Half  Russia,  Qllt,  Marbled  Edges,  $37.00  net. 


11!  U' 


SYNOPSIS  OF  CONTENTS 

VOLUME  L— Upper  Extremity— Back  of  Neck,  Shoulder,  and  Trunk— Cranium— Scalp- 
Face. 

VOLUME  n.—Necfc— Mouth,  Pharynx,  Larynx,  Nose— Orbit— Eyeball— Organ  of  Hearing- 
Brain — Female  Perineum — Male  Perineum. 

VOLUME  m.— Abdominal  Wall— Abdominal  Cavity— Pelvic  Cavity— Chest— Lower  Ex- 
tremity. 

The  book  is  desig^ned. to  aid  the  general  practitioner  and  surgeon  in  his 
everyday  work.  The  text  is  excellently  clear,  succinct,  and  systematically  arranged, 
and  contains  a  wealth  of  illustrations  far  in  advance  of  the  usual  text-book.  It  is  not 
intended  merely,  for  the  surgeon — though  to  him  it  will  prove  invaluable — but  for  the 
general  physician,  who,  while  called  upon  to  cope  with  innumerable  emergencies  and 
special  cases,  has  not  the  means  or  the  hospital  facilities  by  which  he  can  readily 
acquaint  himself  with  every  phase  of  anatomy — supc .  ficial  and  deep — as  applied  to 
disease  and  the  most  modern  methods  of  treatment  of  injuries. 

To  the  specialist  it  will  prove  of  great  value.  The  anatomy  of  the  head  and 
neck,  the  spinal  cord,  the  organs  of  sense,  and  the  throat  appeals  directly  to  the 
ophthalmologist,  aurist,  rhinologist,  laryngologist,  and  neurologist,  while  those  sections 
devoted  to  the  abdomen  and  pelvic  cavity  will  give  the  gynecologist  and  specialist 
on  diseases  of  the  urinary  organs,  rectum,  etc.,  material  regarding  the  relations  of  the 
parts  and  the  operations  thereon,  unique  in  many  ways,  and  in  a  manner  never  before 
so  exactly  and  concisely  stated.  To  those  devoted  to  these  specialties  it  will  prove  a 
supplement  to  other  text-books  that  omit  special  anatomy,  and  which  do  not  attempt 
to  show  the  applied  anatomy. 


.TOMY 


tt't  Hospiial; 

van 


ty  Full-page  Plates, 


'OCCO, 

onet. 


-Qanium — Scalp — 
Organ  of  Hearing— 
■Chest— Lower  Ex- 


d  surgeon  in  his 
atically  arranged, 
;t-book.  It  is  not 
lable — but  for  the 
emergencies  and 
h  he  can  readily 
;p — as  applied  to 

of  the  head  and 
Is  directly  to  the 
lile  those  sections 
ist  and  specialist 
le  relations  of  the 
iner  never  before 
Es  it  will  prove  a 
h  do  not  attempt 


Deaver's  Surgical  Anatomy 


The  illustrations^  which  at  the  first  glance  appear  as  the  prominent  feature  of 
the  book — but  which  in  reality  do  not  overshadow  the  text — consist  of  a  series  of 
pictures  absolutely  unique  and  fresh.  They  will  bear  com])arison  from  an  artistic  point 
of  view  with  any  other  work,  while  from  a  practical  point  of  view  there  is  no  other 
volume  or  series  of  volumes  to  which  they  can  be  compared.  When  originally  an- 
nounced, the  book  was  to  contain  two  hundred  illustrations.  As  the  work  of  prepara- 
tion progressed,  this  number  gradually  increased  until  it  is  estimated  that  there  will  now 
be  more  than  four  hundred  full-page  plates,  many  of  which  contain  more  than  one 
figure.  VVith  the  exception  of  a  few  minor  pictures  made  from  preparations  in  the 
possession  of  the  author,  they  have  all  been  drawn  by  special  artists  from  dissections 
made  for  the  purpose  in  the  dissecting-rooms  of  the  University  of  Pennsylvania.  Their 
accuracy  cannot  be  questioned,  as  each  drawing  has  been  submitted  to  the  most  careful 
scrutiny. 

From  The  Medical  Record^  New  York. 

"  The  reader  is  not  only  taken  by  easy  and  natural  stages  from  the  more  superficial  to  the 
deeper  regions,  but  the  various  important  regional  landmarks  are  also  indicated  by  schematic 
tracing  upon  the  limbs.  Thus  the  courses  of  arteries,  veins,  and  nerves  are  indicated  in  a  way  that 
makes  the  lesson  strikingly  impressive  and  easily  learned  No  expense,  evidently,  has  been 
spared  in  the  preparation  of  the  work,  judging  from  the  number  of  full-page  plates  it  contains,  not 
counting  the  smaller  drawings.  Most  of  these  have  been  '  drawn  by  special  artists  from  dissections 
made  for  the  purpose  in  the  dissecting-rooms  of  the  University  of  Pennsylvania.'  In  summing  up 
the  general  excellences  of  this  remarkable  work,  we  can  accord  our  unqualified  praise  for  the 
accurate,  exhaustive,  and  systematic  manner  in  which  the  author  has  carried  out  his  plan,  and  we 
can  commend  it  as  a  model  of  its  kind>  which  must  be  possessed  to  be  appreciated." 

From  The  Philldelphia  Medical  Journal. 

"  Many  members  of  the  profession  to  whom  Dr.  Deaver  is  well  known  either  personally  or  by 
reputation  as  a  surgeon,  writer,  teacher,  and  practical  anatomist,  have  awaited  the  appearance  of 
his  Surgical  Anatomy  with  the  expectation  of  finding  in  it  a  guide  in  this  difficult  branch  of  medi- 
cine of  niur  'i       re  than  ordinary  practical  value,  and  their  expectations  will  not  be  disappointed." 

From  The  Journal  of  the  American  Medical  Association. 

"  In  order  to  shov/  its  thoroughness,  it  is  only  necessary  to  mention  that  no  less  than  twelve 
full-page  plates  are  reproduced  in  order  to  accurately  portray  the  surgical  anatomy  of  the  hand, 
and  it  is  doubtful  whether  any  better  description  exists  in  any  work  in  the  English  language." 

From  The  Soutfiem  California  Practitioner. 

"  Aside  from  the  merit  of  this  great  work,  it  will  be  a  delight  to  the  lover  of  books.  Its  gen 
eral  make-up  shows  the  highest  development  of  the  book-making  art.  The  bibliophile,  when 
holding  one  of  these  volumes  in  his  hands,  would  be  as  careful  with  it  as  though  he  were  handling 
an  infant,  and  to  drop  it  would  cause" him  the  keenest  pain.  The  illustrations,  the  print,  and  (lie 
paper  and  binding  are  each  and  all  delightful  in  themselves,  and  yet  the  text  is  concise  and  clear, 
and  taken  with  the  illustrations  make  a  remarkably  good  substitute  for  the  dissecting-room.  To 
have  these  three  volumes  on  his  library  shelves  will  be  a  source  of  pride  and  joy  and  profit  to 
every  practitioner.  Dr.  Deaver  has  in  these  volumes  conferred  a  boon  upon  the  medical  profession 
which  has,  at  least,  never  been  surpassed  by  any  one." 

From  The  New  Orleans  Medical  and  Surgical  Journal. 

"  While  the  needs  of  the  undergraduate  have  been  fully  kept  in  view,  it  has  been  the  aim  of 
the  author  to  provide  a  work  which  would  be  sullicient  for  reference  for  use  in  actual  practice.  We 
believe  the  book  fulfils  both  requirements.  The  arrangement  Is  systematic  and  the  discussion  of 
surgical  relations  thorough." 

ffeS"  Large  Descriptive  Circular  will  be  sent  upon  application 

45 


4^ 


Hcmmctcr^     Diseases  of  the  Stomach.     Second 
Edition^  Enlarged.     Illustrated. 

Their  Special  Pathology,  Diagnosis,  and  Treatment.  With  Sections  on  Anatomy, 
Analysis  of  Stomach  Contents,  Dietetics,  Surgery  of  the  Stomach,  etc.  By  John 
C.  Hkmmkter,  M.D.,  PHiLOS.D.,  Professor  in  the  Medical  Department  of  the 
University  of  Maryland  ;  Consultant  to  the  University  Hospital ;  Director  of  the 
Clinical  Laboratory,  etc.  Second  Revised  Edition.  With  Colored  and  other 
Illustrations.     Octavo.     890  pages. 

Cloth,  ji(6.oo  ;    Leather,  #7.00;    Half  Russia,  #8.00 

*^*  The  rapid  sale  of  the  first  edition  of  this  book  has  encouraged  the  author  to 
revise  it  very  thoroughly  and  to  add  much  new  material  (about  100  pages)  and  a  num- 
ber of  new  illustrations.  About  two-thirds  of  the  book  has  been  actually  reconstructed. 
The  section  on  Dietetics  will  be  found  particularly  useful. 

"  A  second  enlarged  and  revised  edition  appearing  in  a  little  over  a  year  from  the  date  of  the 
original  publication  speaks  for  the  popularity  and  value  of  the  work.  This  book  easily  occupies 
the  first  place  among  its  sort  in  the  English  language  and  is  particularly  free  from  that  enthusiastic 
hobby  riding  which  is  not  unknown  among  gastroenterologists.  The  bibliographical  references 
are  very  full  and  complete,  and  the  work  is  one  of  the  highest  order  as  well  as  one  of  the  utmost 
practical  value." — Chicago  Medical  Recorder. 

"  This  edition  of  Ilemmeter's  work  on  '  Diseases  of  the  Stomach '  contains  much  new  and 
important  material.  The  following  articles  have  been  added  :  Hypertrophic  stenosis  of  the  pylorus, 
obstruction  of  the  orifices,  the  use  and  abuse  of  rest  and  exercise  in  the  treatment  of  digestive  dis- 
eases. Part  of  the  chapter  on  motor  insufficiency,  electrodiaphany,  hemorrhage  from  the  stomach, 
and  the  articles  on  gastroptosis  and  enteroptosis  have  been  entirely  rewritten.  The  present  edition 
will  undoubtedly  gain  as  many  friends  as  the  first  edition." — The  Medical  Record,  Nnu  York. 

"Dr.  Hemmeter  certainly  provides  a  book  which  is  well  worthy  of  a  careful  study.  ...  It 
treats  of  many  subjects  in  an  original  manner,  and  is  not  only  based  on  a  considerable  personal 
experience,  but  takes  due  notice  of  the  labors  of  other  well-known  workers  in  this  field." — British 
Medical  Journal. 

"  Completely  scientific,  modern,  accurate,  and  creditable.  .  .  .  We  co,rimend  it." — Journal 
of  the  American  Medical  Association. 

"We  know  of  no  work  from  which  the  physician  may  gain  more  information  than  this. " — 
Australian  Medical  Gazette. 

"  The  consideration  of  die  general  methods  of  clinical  examination  of  the  stomach  is  thor- 
oughly adequate. ' ' — Boston  Medical  and  Surgical  Journal. 

"  We  part  from  Dr.  Hcmmeler's  book  with  the  sense  that  it  embodies  tlie  best  knowledge  of 
the  time." — London  Lancet. 

"  We  wish  to  express  unqualified  approval  of  the  tendency  which  is  shown  to  emphasize  the 
simple  and  more  practical  mi?ihods  of  diagnosis." — New  York  Medical  Journal. 

"The  best  contemporary  treatise  on  diseases  of  the  stomach  which  we  possess,  not  oidy  in 
America,  but  in  the  whole  world." — Prof.  I.  Boas,  of  Berlin. 


In  Preparation  by  the  same  Author 

Diseases  of  the  Intestines.    Original  Iflustrations 

A  Complete,  Systematic  Treatise,  Including  the  Surgical  Aspects  of  the  Subject. 

46 


►     Second 


ions  on  Anatomy, 
h,  etc.  By  John 
cpartment  of  the 
Director  of  the 
olored  and  other 

falf  Russia,  #8.00 

iped  the  author  to 
;i},'es)  and  a  num- 
illy  reconstructed. 

from  the  date  of  the 
look  easily  occupies 
'om  that  enthusiastic 
graphical  references 
s  one  of  the  utmost 

ains  much  new  and 
nosis  of  the  pylorus, 
lent  of  digestive  dis- 
;e  from  the  stomach, 
Tlie  present  edition 
[ori/,  Nru)  York. 

sful  study,  ...  It 
:onsf(lerable  personal 
this  i\AA:'— British 

imend  it." — Journal 
mation  than  this." — 
he  stomach  is  thor- 
e  l)cst  knowledge  of 


ivn  to  emphasi/e  the 
possess,  not  only  in 


ustrations 

of  the  Subject. 


Gordinicr*  The  Gross  aiid  Minute  Anatomy 
of  the  Central  Nervous  System.  G)Iored 
Illustrations* 

By  H.  C.  GoRDiNiER,  A.M.,  M.D.,  Professor  of  Physiology  and  of  the  Anatomy 
of  the  Nervous  System  in  the  Albany  Medical  College  ;  Member  American  Neuro- 
logical Association.  With  48  Full-page  Plates  and  213  other  Illustrations,  a 
number  of  which  are  printed  in  Colors  and  many  of  which  are  original.  Large 
8vo.  Cloth,  $6.00  ;  Sheep,  $7.00  ;  Half  Russia,  58.00. 

*^  It  is  universally  acknowledged  that  for  a  proper  comprehension  of  the  normal 
and  abnormal  activities  of  an  organ  a  thorough  knowledge  of  its  anatomy  is  absolutely 
essential.  This  is  particularly  true  of  diseases  of  the  central  nervous  system,  for  in  no 
other  way  can  the  disease  symptoms  be  explained.  Without  this  knowledge,  clinical 
and  pathologic  observations  are  of  little  avail.  This  book  is  not  a  theoretic  and  tech- 
nical student's  book,  but  a  useful  working  supplement  to  all  works  upon  general  practice 
and  neurology,  and  as  such  is  destined  to  mark  an  epoch  in  medical  literature. 

"  This  is  an  excellent  book  fln  a  fascinating  subject,  and  the  author  deserves  the  thanks  of  the 
English-speaking  medical  world  for  his  labor  in  getting  it  up.  There  are  works  enough  on  genenal 
anatomy,  and  dry  enough  they  are,  as  we  all  remember  only  too  well;  but  the  anatomy  of  the 
nervous  system  alone  is  another  matter  entireiy,  for  it  is  one  of  the  most  interesting  of  all  subjects 
of  medical  sttfdy,  at  the  same  time  that  it  is  one  of  the  most  difficult.  For  both  of  these  reasons 
the  subject  is  deserving  of  a  treatise  by  itself,  and  should  not  be  briefly  discussed  in  a  few  pages 
of  a  general  work  on  anatomy,  or  in  an  introductory  chapter  of  a  treatise  on  diseases  of  the  ner- 
vous system." — Medical  Record,  A'ew  York. 

"  The  author  has  made  an  honest  attempt  to  place  in  the  hands  of  the  English  student  a 
comprehensive  and  accur.ite  textbook,  devoid  of  the  many  intricacies  of  modern  thought  and 
speculation.  For  the  average  man  the  work  will  appe.il  strongly ;  the  facts  that  he  can  use  are 
readily  found. ' ' —  The  Journal  of  A'en'ous  and  Menhil  Diseases,  A'nv  York. 

"  Throughout  the  book  the  descriptions  of  the  gross  and  minute  anatomy  are,  as  a  rule,  clear, 
objective,  and  as  easy  of  comprehension  as  could  be  expected  of  so  difficult  a  subject.  The  state- 
ments are  most  of  them  quite  didactically  made,  but  this  we  consider  an  advantage  rather  than  a 
defect,  especially  in  a  text-book  for  students  as  well  as  practitioners.  .  .  .  The  chapter  on 
cerebral  localization  is  carefully  written,  and  gives  the  most  recent  results  on  the  subject." — 7'he 
American  Journal  of  Insanity,  Baltimore. 

"  Represents  much  painstaking  rese.irch,  and  bears  also  the  stamp  of  origin.il  investigation. 
It  is  unusually  well  written,  and  the  illustiations,  many  of  whicli  are  original,  are  well  chosen.  It 
is  destined  to  take  its  place  among  the  standard  books  of  its  class." — New  York  Medical  Journal. 

"  This  book  will  be  welcomed  by  teachers,  practitioners,  and  students.  It  will  save  teachers 
and  writers  on  the  nervous  system  the  necessity  of  accompanyinij  tlieir  lectures  and  iiooks  on 
diseases  of  the  nervous  system  with  chapters  on  anatomy.  It  is  really  the  first  thoroughly  system- 
atic work  on  the  anatomy  of  the  central  nervous  system  that  has  appeared  in  the  English  language. 
The  work  is  the  more  necessary  because  diseases  of  the  central  nervous  system  are  becoming  mote 
f.nd  more  recognized,  and  because  the  works  on  general  anatomy  do  not  pretend  to  describe  the 
minute  anatomy  of  the  central  nervous  system.  Authors  of  books  on  neurology  rccogni/e  the  fact 
that  their  readers  cannot  understand  the  descriptions  of  the  diseases  of  the  central  nervous  system 
without  a  knowledge  of  the  anatomy  of  the  parts  involved.  The  subject  is  a  difticult  one  at  best, 
but  the  stmlent  who  will  make  an  earnest  effort  to  master  the  details  cannot  fail  to  do  so  with  the 
aid  of  this  work.  The  author's  descriptions  are  clear,  concise,  comprehensive,  and  profusely  and 
beautifully  illustrated." — Pacific  Medical  Journal,  San  Francisco. 

"  .As  there  can  he  no  accurate  understanding  of  the  diseases  of  the  nervous  system  without  a 
thorough  knowledge  of  the  anatomy,  it  fs  no  wonder  tliat  the  average  practitioner  is  as  ignorant  of 
neurology  as  is  unfortunately  the  c.ise.  '1  he  present  volume  is  a  praiseworthy  attempt  to  remove 
the  approach  that  h.as  thus  far  re3ted  upon  English  and  American  neurology." — Boston  Medical 
and  Surgical  Journal. 

"  We  commend  Gordinier's  chapter  on  cerebral  localization.  This  will  be  especially  helpful  to 
clinicians,  although  all  the  views  expressed  in  it  are  not  yet  outside  of  the  domain  of  controversy. 
Ve  should  like  to  say  more  about  Gordinier's  book,  but  space  forbids.  It  is  handsomely  printed 
and  copiously  illustrated,  and  we  can  recommend  it  as  a  good  text-book  of  nervous  anatomy." 
— Philadelphia  Medical  Journal. 

47 


Sir 


JUST  READY 

PRACTICAL  GYNECOLOGY 

A  Modern  Comprehensive  Text-Book 
By  E.  E.  MONTGOMERY,  M.D. 

Profcnor  of  Gynecology,  Jefferaon  Medical  College  t  Gynecologist  to  the  Jcfferion  Medical 

College  and  St.  Joseph's  Hospitals;  Consulting  Gyncwloglst  to 

the  Philadelphia  Lying-in  Charity 

WITH  FIVE  HUNDRED  AND  TWENTY-SEVEN 
ILLUSTRATIONS  • 

Nearly  all  of  which  have  been  Drawn  and  Engraved  Specially  for  this 
Work,  for  the  most  part  from  Original  Sources 

OCTAVO.    8J9  PAGES 
CLOTH,  $5.00;   LEATHER,  $6.00;  HALF  RUSSIA,  $7.00 


I- 1 


I 


EXTRACT  FROM  THE  PREFACE 

This  work  has  been  under  consideration  for  the  past  fifteen  years,  and  much  of  it 
has  been  several  times  rewritten.  An  effort  has  been  made  to  make  it  a  comprehensive 
work  upon  the  subject,  givifig  the  experience  and  methods  of  the  most  careful  men, 
while  my  own  experience  has  been  utilized  to  indicate  that  which  I  have  found  most 
useful  and  worthy  of  acceptance. 

Each  general  subject  is  considered  with  reference  to  its  influence  upon  the  entire 
■genital  tract,  and  the  work  is  divided  into  sections  rather  than  chapters.  This  course, 
although  a  departure  from  the  ordinary  text-book  arrangement,  is  that  which  experience 
has  demonstrated  to  be  most  effective  in  impressing  the  subject  upon  the  student,  and 
would  seem  to  me  preferable  to  him  who  uses  the  book  to  refresh  his  knowledge  upon 
some  particular  subject.  The  illustrations  are  arranged  solely  with  the  purpose  of 
rendering  clear  the  text  and  to  promote  the  work  of  diagnosis  and  treatment.  For  the 
excellence  and  character  of  the  illustrations  1  am  greatly  indebted  to  the  generosity  of 
the  publishers  and  to  the  skill  and  patience  of  their  artists,  Messrs.  Shannon  and  Von 
du  Lancken.  To  the  kindly  oversight  of  Dr.  Robert  L.  Dickinson  is  due  much  of  the 
exactness  of  the  drawings.  Acknowledgment  is  due  Miss  Eleanor  A.  Cantner  for  her 
ability  in  the  preparation  of  preliminary  sketches  and  of  the  index. 

Should  it  be  the  means  of  lightening  the  work  of  the  student,  of  making  more 
dear  the  pathway  of  the  busy  practitioner,  and,  most  of  all,  of  benefiting  suffering 
women  thiough  improved  methods  of  diagnosis  and  treatment,  I  shall  feel  well  repaid 
for  the  many  days  and  nights  of  labor  which  it  has  cost. 

48 


.OGY 

non  Medical 

V-SEVEN 

lly  for  this 


,$7.00 


ars,  and  much  of  it 

e  it  a  comprehensive 

;  most  careful  men, 

I  have  found  most 

lence  upon  the  entire 
ipters.     This  course, 
hat  which  experience 
ipon  the  student,  and 
his  knowledge  upon 
with  the  purpose  of 
1  treatment.     For  the 
;d  to  the  generosity  of 
rs.  Shannon  and  Von 
in  is  due  much  of  the 
lor  A.  Cantner  for  her 

X. 

dent,  of  making  more 
of  benefiting  suffermg 
[  shall  feel  well  repaid 


